Fillable CONFIDENTIAL V00 exceptional circumstances. Student Information (please print) (University of Victoria)

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CONFIDENTIAL V00 exceptional circumstances. Student Information (please print) (University of Victoria)

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Office of the Registrar
PO Box 3025 STN CSC
Victoria, BC V8W 3P2
Main floor
University C
entre
studentsupport@uvic.ca
FAX: 250-721-6225
Request for Academic Concession (RAC) for
Undergraduate Students
CONFIDENTIAL
Complete this form only if the final drop deadline has passed and you are applying for one or more of
the following:
Deferral (DEF), unable to complete course requirements by end of term.
Extended deferral (EXTDEF), unable to complete course requirements by end of time approved for
deferral.
Aegrotat (AEG) grade, notation to be added to grade indicating it was assigned under extenuating or
exceptional circumstances.
Withdrawal (WE) from course(s) under extenuating circumstances.
Drop, approved in limited cases. Include justification why the course should be removed from your
academic record
Student Information (please print)
Student Number
V00
Last Name
First Name
Telephone Number
Important Information & Instructions
Students seeking to withdraw from a course before the final drop deadline should use the online registration system. Students
who drop a course because of accident, illness or affliction may appeal for a reduction in fees for the course(s) dropped by
submitting an “Appeal for Fee Reduction to the Fee Reduction Appeal Committee (FRAC) (see
www.uvic.ca/vpfo/accounting/assets/docs/tuition/Appeal-fee-reduction-form.pdf).
Important information regarding Undergraduate Academic Concession Options and Procedures can be found at
http://www.uvic.ca/registrar/students/appeals/
Complete this form in full. You must provide supporting documentation and/or the Professional’s Statement in Support of
Request for Academic Concession (see pages 3 and 4). Return the completed form to the Office of the Registrar.
The University of Victoria recognizes that students submitting a Request for Academic Concession are dealing with exceptional
circumstances. Guidance and support is recommended prior to registering for future courses. Students should consult with an
academic advisor, counsellor, disability advisor, or health care provider, as appropriate. Note that decisions to defer or
withdraw from courses may have implications for financial aid. Check with Student Awards and Financial Aid.
This request and supporting documentation are retained in a restricted-access confidential student file.
Type of Academic Concession Requested
Type of Academic Concession
(Select one)
(e.g. FRAN 100)
Lecture
CRN
(e.g. 12456)
Lab or
Tutorial CRN
(e.g. Fall 2013)
Dean’s Decision
(Office Use Only)
Deferral Extended Deferral Aegrotat
Withdrawal – Extenuating Circumstances Drop
WE Drop Not Approved
100% 50% Academic Deadline
Deferral Extended Deferral Aegrotat
Withdrawal – Extenuating Circumstances Drop
WE Drop Not Approved
100% 50% Academic Deadline
Deferral Extended Deferral Aegrotat
Withdrawal – Extenuating Circumstances Drop
WE Drop Not Approved
100% 50% Academic Deadline
Deferral Extended Deferral Aegrotat
Withdrawal – Extenuating Circumstances Drop
WE Drop Not Approved
100% 50% Academic Deadline
Deferral Extended Deferral Aegrotat
Withdrawal – Extenuating Circumstances Drop
WE Drop Not Approved
100% 50% Academic Deadline
Deferral Extended Deferral Aegrotat
Withdrawal – Extenuating Circumstances Drop
WE Drop Not Approved
100% 50% Academic Deadline
Deferral Extended Deferral Aegrotat
Withdrawal – Extenuating Circumstances Drop
WE Drop Not Approved
100% 50% Academic Deadline
Dean’s Signature: ____________________________________ Date: ________________________________________
For Office of the Registrar use only:
SFAREGS:
FACULTY: SHATCKN:
SPACMNT:
SPACMNT:
Received:
Initial:
Form last updated: Feb 2019 Continue on page 2
Page 1 of 4
Email address
I have applied to graduate and recognize that Requests for Academic
Concessions may affect my eligibility to graduate. Contact
mygrad@uvic.ca for details.
Supporting documentation required for a Request for Academic Concession:
1. Prepare a typed statement explaining how completion of course requirements has been interfered with. If you are
requesting a deferral or an extension of a deferral, you must include your plan and timeline for completion of the
coursework. If a typed statement is not possible, please use the space provided below to write your statement.
and
2. Provide supporting documentation. Note, for a death in the immediate family, an obituary is acceptable as
documentation. For other circumstances, please submit a completed Professional Statement in Support of
Request for Academic Concession (see page 4) OR other documentation completed by a third party that
establishes that you cannot complete the course because of accident, illness or affliction.
See attached or Hand-write your personal statement below (if a typed statement is not possible)
By signing below I, the applicant, consent to the collection and use of personal information about me for the purpose of
determining whether academic concession(s) are warranted and academically appropriate.
I, __________________________________ agree to the following:
a) I have accurately represented my circumstances on this form and in my personal statement.
b) I understand that any health or counselling professionals who have provided supporting documentation may be contacted to
discuss their statement. I have discussed this with these professionals and given permission for this contact and for them to
discuss my request.
c) I understand that the instructors for the course(s) listed may be contacted to discuss my attendance and academic
performance.
d) I am aware that this form, personal statement and supporting documentation I submit will remain in my confidential student
file and may be consulted in the consideration of other requests for academic concession, both current and in the future.
Student
’s Signature: _______________________________________ Date: ____________________________________________
The University of Victoria collects, uses, discloses and retains personal information only in compliance with the University Act and the British Columbia Freedom of Information and
Protection of Privacy Act. The University of Victoria collects the personal Information on this form and on the Professional Statement pursuant to section 26(a) and (c) of the Freedom of
Information and Protection of Privacy Act. The information provided in this form will be used only for the purposes related to requests for academic concessions. For a detailed listing of
the types of Personal Information the University collects and the purposes for such collection see Schedule A, Procedures for the Management of Personal Information. Should you have
any questions concerning your personal information, please contact the University Secretary’s office at foipp@uvic.ca or (250) 472-4914.
Continue on page 3
Page 2 of 4
Professional’s Statement in Support
of Request for Academic Concession
Student Number
V00
First Name
Last Name
Section A To be completed by the student
My reason(s) for seeking academic concession occurred during the following time frame:
Start date: ___________________________ End date (if known): ___________________________
I authorize ___________________________________ to disclose information about my medical or personal
condition(s) for the purpose of determining whether there are grounds for granting an academic concession.
Student’s Signature: _______________________________ Date: _______________________________
Section B To be completed by the student
I am requesting this concession because the following course components are/were not completed
(note – course components include exams, attending classes and assignments)
Course Name and Number
(e.g. FRAN 100)
Indicate how many course components are/were not completed
(e.g. 2 Exams, 1 Assignments)
□All or __ Exams __ Attending Classes __ Assignments __Essays __ Other*
□All or __ Exams __ Attending Classes __ Assignments __Essays __ Other*
□All or __ Exams __ Attending Classes __ Assignments __Essays __ Other*
□All or __ Exams __ Attending Classes __ Assignments __Essays __
Other*
□All or __ Exams __ Attending Classes __ Assignments __Essays __ Other*
□All or __ Exams __ Attending Classes __ Assignments __Essays __ Other*
□All or __ Exams __ Attending Classes __ Assignments __Essays __ Other*
□All or __ Exams __ Attending Classes __ Assignments __Essays __ Other*
Section C
To be completed by a health or counselling professional
CONTACT INFORMATION OR OFFICE STAMP
* Describe other course component if indicated above
Continue on page 4
Page 3 of 4
Professional’s Statement in Support
of Request for Academic Concession
SECTION D To be completed by a health or counselling professional
1. Do you have sufficient information to speak to this student's ability to complete coursework during the time period
indicated by the student?
Yes No
If no, what time period can you speak to? Start date: _________________ End date: ___________________
2. Based on the information available to you, do you believe the student’s academic performance would have been
affected during the time period indicated?
Yes No
3. To assist in determining whether the concession requested is appropriate please provide information about how the
student’s academic performance could have been impacted by his or her circumstances. You may use the checklist
below, and/or the comments section, or provide a separate written statement.
Instead of this checklist I have used: ☐ the Comments section ☐ a separate written statement
Impacted
Not Impacted
Not Applicable
Ability to attend class on a regular basis
Ability to use course materials such as readings, websites
Ability to concentrate and retain information
Ability to complete homework assignments
Ability to complete writing assignments/essays/papers
Ability to write exams
Ability to interact with instructors
Ability to undertake COOP/practicum
Further Comments
IMPORTANT: Please be sure to provide contact info in Section C, on page 3 of this form.
_____________________________________ _____________________________________ _____________________
Name of professional (please print) Signature of Professional Date
Page 4 of 4
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CONFIDENTIAL V00 exceptional circumstances. Student Information (please print) (University of Victoria)

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Completed 1 November 2021

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