Fillable ELICOS ONLY Application for SPECIAL CONSIDERATION IN ASSESSMENT (Swinburne University of Technology)

Fill Online, Printable, Fillable, Blank ELICOS ONLY Application for SPECIAL CONSIDERATION IN ASSESSMENT (Swinburne University of Technology) Form

Use Fill to complete blank online SWINBURNE UNIVERSITY OF TECHNOLOGY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

ELICOS ONLY Application for SPECIAL CONSIDERATION IN ASSESSMENT (Swinburne University of Technology)

On average this form takes 16 minutes to complete

The ELICOS ONLY Application for SPECIAL CONSIDERATION IN ASSESSMENT (Swinburne University of Technology) form is 3 pages long and contains:

  • 0 signatures
  • 33 check-boxes
  • 50 other fields

Country of origin: AUSTRALIA
File type: PDF

Australia forms for Swinburne University of Technology

BROWSE SWINBURNE UNIVERSITY OF TECHNOLOGY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Foundation and Pathways Department, Swinburne University of Technology
Last updated: 12/02/2019
ELICOS ONLY
Application for SPECIAL CONSIDERATION IN ASSESSMENT
INSTRUCTIONS: Please read carefully before completing this application. Make sure you fill in all
required details, or the application cannot be assessed.
To be eligible for Special Consideration (which includes Special Examination) a student must meet one of
the following criteria and attach documentary evidence (e.g. Medical Impact Statement):
• at any time during the academic teaching period, a student’s study has been affected by illness or
other extraordinary cause to a significant degree; or
• a student has been affected, to a significant degree, by illness or other extraordinary cause and is
prevented from preparing or presenting for all or part of assessment such as assignments and
examinations.
This application must be lodged at TD Reception to the attention of EAP Coordinator or the GE
Coordinator no later than 5pm on the second working day after the submission date for a piece of
assessment or the date of the exam for which Special Consideration is claimed.
The application will be considered on the basis of the evidence presented to support the case, provided
that:
• the completed and signed application form is lodged no later than 5pm on the second working day
after the due date of the assessment; and
• the circumstances (illness or extraordinary cause) were beyond the student’s control; and
• the circumstances (illness or extraordinary cause) resulted in a severe impact or total incapacitation of the
student’s performance; and
• supporting documentation is attached to the application and page 3 has been signed and stamped by a
Medical Practitioner and/or Counsellor in accordance with Swinburne’s Special consideration
regulations. Please note that for non-medical reason i.e. death in family, car accident, subpoena for
court attendance, a statutory declaration, correctly completed, can also be accepted)
https://www.swinburne.edu.au/current-students/manage-course/exams-results-assessment/special-
consideration-adjustments-extensions/special-consideration/
The ELICOS Management will advise student of the outcome of this application within two (2)
working days of receipt of the application.
SECTION A Student Personal Details – All fields required to be completed
STUDENT ID:
FAMILY NAME:
GIVEN NAMES:
MOBILE:
EMAIL ADDRESS:
CURRENT ELICOS LEVEL:
TEACHERS:
Which exam(s) do you need to apply for Special Consideration for? (Please tick the box)
Level? (e.g. EAP3A)
Assignment or Exam
Exam Date
☐ Listening
☐ Writing
☐ Quiz
☐ Reading
☐ Speaking
☐ Project
☐ Listening
☐ Writing
☐ Quiz
☐ Reading
☐ Speaking
☐ Project
☐ Listening
☐ Writing
☐ Quiz
☐ Reading
☐ Speaking
☐ Project
☐ Listening
☐ Writing
☐ Quiz
☐ Reading
☐ Speaking
☐ Project
☐ Listening
☐ Writing
☐ Quiz
☐ Reading
☐ Speaking
☐ Project
SECTION D Student Declaration – All fields required to be completed
I hereby apply for Special Consideration for the stated units of study. I declare that the information I have provided in
this application and on the attached documentation is true and correct in every detail. Where a medical impact
statement is attached, I authorise Swinburne University of Technology to seek information directly from the
originating source. I have read and understand the guidelines printed on this form.
Student signature
Date
OFFICE USE ONLY
Please date receipt of form and forward to the EAP Coordinator, or GE Coordinator
Date of Receipt
Documents Attached (Y/N & Number)
Practitioner's stamp
Registered Practitioner Statement
This statement must be completed by a registered medical/health practitioner for a student whose work for a piece of assessment,
including examinations, has been adversely affected. Swinburne University of Technology will give special consideration to students
only in circumstances of an acute illness, condition or extraordinary event beyond their control. Guidelines for completing this form
are on Page 2.
1. Registered Practitioner Assessment
I,______________________________________________ (name), a registered medical/health practitioner, declare that I had a consultation
with ______________________________________________ (student’s name) on _________________ (date) and in my opinion have determined:
the student is diagnosed with/experiencing ___________________________________ or
the student is experiencing an illness of a confidential nature or
the student stated ___________________________________, however, I am unable to assess as symptoms are no longer present.
We have discussed the nature of the illness that this student is experiencing and I have determined that in regard to the student’s
capacity to attend classes, complete assessment requirements or sit an examination, the student has been assessed as:
Additional comments:
2. Registered Practitioner Details
Practitioner name _________________________________________ Contact no. ____________________________________
Address _______________________________________________________________________________________________
Provider/Registration no. _______________________________
I declare that I am not a family member and do not have a close or personal relationship with this student.
I authorise Swinburne to contact me or my office to confirm the authenticity of this document.
Practitioner’s signature ________________________________________________ Date*______/______/______
*Date the statement was issued
3. Student Information and Authority
Student ID number _______________ Family name ________________________________________ Given
name(s)________________________________________
I hereby consent to relevant information being provided by my medical/health practitioner and agree that they may provide verification of this
statement if requested by Swinburne. I understand that I must retain the originals of any documents submitted in support of a special consideration
request and that Swinburne may require the originals to be supplied at any time during my enrolment until my degree has been conferred, or my
enrolment otherwise terminated.
Student’s signature _________________________________________________ Date ______/______/______
Degree of Impact
From (date)
To (date)
Minor impact – the condition is not serious and has not had a significant impact on the student’s
ability to attend class/complete assessment(s)/sit an examination.
Moderate impact – the condition has caused considerable discomfort but has not had a severe impact
on their ability to attend class/complete the assessment task/sit an examination.
Severe impact – the condition has severely affected the student and they are unable to attend
class/complete the assessment(s)/sit an examination or their level of performance in an examination
will be affected.
Total incapacitation – the condition has affected the student to such an extent that they are totally
unable to attend class/undertake the assessment task/sit an examination e.g. bedridden, hospitalised
or broken dominant hand.
Guidelines for Registered Practitioner Statement
Swinburne University of Technology appreciates you taking the time to help our student assess the
impact of their illness or injury. The information you provide here will ensure that the assessment
process is fair and equitable.
These guidelines have been written to assist you, as a medical/health practitioner, to understand the
purpose and use of the university’s Registered Practitioner Statement in the special consideration
process.
The purpose of special consideration is to give a student, whose work for a particular piece of
assessment has been adversely affected by an extraordinary event beyond their control, a further
opportunity to demonstrate their ability.
1. Use of the Registered Practitioner Statement
This statement is included in the application that a student submits to Swinburne for special
consideration. It will allow Swinburne to verify the student’s claim and to determine the form of
consideration to be given based on the student’s circumstances.
The information you supply on this document will be available to those staff who need access to it in
order to carry out their duties in accordance with Swinburne’s privacy policy.
2. What is special consideration granted for?
Special consideration is granted to a student in circumstances of acute illness or condition, or an
extraordinary circumstance which has directly impacted their ability to perform an assessment task.
Please be aware that Swinburne has a variety of support services available for students who may be
experiencing chronic illness or disability. They include AccessAbility Services (for assessment and
examination adjustments) and Swinburne Health Services (for counselling and psychological services and
general medical treatment).
3. What information must a Registered Practitioner Statement include?
The Registered Practitioner Statement must include:
a. The practitioner’s name, contact details, provider or registration number and
signature
b. The date of the consultation
c. An evaluation by the practitioner, psychologist, etc. of the duration and degree of impact on
the student’s ability to attend classes, study or complete assessment requirements
d. The date the statement was written and signed.
The Registered Practitioner Statement is to be completed by a registered medical/health practitioner
within the scope of their practice, who is not a family member and does not have a close or personal
relationship with the student.
Please issue the statement in line with guidelines provided by your professional association and only in
respect of an illness, injury or extraordinary circumstances that you have observed. Please do not
provide post-dated statements, as these will not be accepted by Swinburne.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

ELICOS ONLY Application for SPECIAL CONSIDERATION IN ASSESSMENT (Swinburne University of Technology)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 4 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document