Fillable Retroactive Hardship Withdrawal Form RevDec2018 Fillable Request for Hardship Withdrawal

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Retroactive Hardship Withdrawal Form RevDec2018 Fillable Request for Hardship Withdrawal

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Revised January 2019
REQUEST FOR RETROACTIVE HARDSHIP WITHDRAWAL
Students may request a hardship withdrawal after the official Drop/Add deadline published in the UWG semester term calendar until the Friday
immediately prior to the final week of the term. A hardship withdrawal is an exception based on unusual or emergency circumstances beyond the
student’s control, and the student must withdraw from all classes during the current term. See page 2 of this form for steps to complete
the process to request the hardship withdrawal.
_____________________ _______________________ ____________ 917 _________________ ______________ _________ _________
LAST NAME FIRST NAME MIDDLE NAME STUDENT ID NUMBER MAJOR SEMESTER YEAR
REQUEST INITIATED THROUGH: (Please Check) COUNSELING CENTER – COUNSELOR HEALTH SERVICES - STUDENT PATIENT ADVOCATE
CONTACT INFORMATION: ____________________________________________ _______________________________ ______ ___________
MAILING ADDRESS CITY STATE ZIP
_________________________________@my.westga.edu ________________________________________________________________
EMAIL ADDRESS TELEPHONE NUMBER(S)
Is this Hardship Withdrawal request being made to appeal your Academic Suspension or Dismissal?
Yes
No
If yes, please indicate your academic status: Suspension One Term Suspension One Year
Academic Dismissal
Please indicate your reason for requesting a hardship withdrawal and attach a written statement regarding the reason for the withdrawal. Be prepared
to provide documentation, means of corroboration, or other evidence as needed.
REASON
(Please Check)
HARDSHIP WITHDRAWAL CATEGORY
SAMPLE DOCUMENTATION TO SUPPORT THE REQUEST
Physical – Examples include bodily injury or invasive surgery
resulting in prolonged absences from class, or unexpected
physical disability preventing completion of course work.
Physician’s report, including name, address, phone, nature of
illness or accidents, dates of treatment, prognosis, and
recommendation
Psychological – Examples include extreme mental duress
suffered from traumatic experiences, of the severity and frequency
to prevent completion of course work.
Memo from UWG Counseling Center counselor or other
professional counselor that includes dates of treatment and a
recommendation of whether a hardship withdrawal be given.
Personal – Examples include significant change in financial status
or personal tragedy such as the death of loved one or domestic
disruptions, to the degree to prevent completion of course work.
Copy of divorce papers, financial statements, police reports,
obituaries, or other pertinent documents.
Please sign to indicate the following: 1) I have contacted the Financial Aid Office and am aware of the financial aid implications
should this request be approved and 2) I am aware this form and all supporting documents including the Counseling and/
or Health Services letter will be viewed by all approvers including the Dean/Designee of the College and the Provost/Designee
STUDENT SIGNATURE (required) __________________________________________________________ DATE _______________________________
COLLEGE /SCHOOL (FOR ALL UNDECLARED MAJORS WRITE HONORS COLLEGE) ___________________________________________________________
*This form must be completed and signed with supporting documentation attached before your hardship withdrawal will be considered.
Courses in which you
are currently enrolled:
Example:
ENGL 1101-01
CRN 10125
Find course section
numbers and t he CRN
in the Class Bulletin in
Banweb.
Please print legibly
COURSE NUMBER AND SECTION CRN INSTRUCTOR’S NAME
H
AVE YOU TAKEN THE FINAL EXAM
OR TURNED IN FINAL WORK
?
YES NO
FOR OFFICIAL USE ONLY
□ RECOMMEND
□ NOT RECOMMEND
□ APPROVED
□ NOT APPROVED
DEAN/DESIGNEE PRINTED NAME__________________________________________________________________________
DEAN/DESIGNEE SIGNATURE AND DATE ___________________________________________________________________
PROVOST/DESIGNEE PRINTED NAME______________________________________________________________________
PROVOST/DESIGNEE SIGNATURE AND DATE _______________________________________________________________
Select
Please Select
Revised April 2016
Under what conditions may a Request for Hardship Withdrawal be approved?
A Hardship Withdrawal is intended as relief for extreme circumstances and is granted only in special instances. The following conditions apply:
• The student must meet the timelines and follow Steps 1-6 below, with emphasis on providing documented evidence in support of the
claims warranting the request.
• The student must withdraw from all classes during the current term, and may not select only certain classes from which to withdraw.
o Under unusual circumstances, a student may be granted a hardship withdrawal from only one class, while being allowed to
remain in others. An example of unusual circumstances would be a student who is passing an applied piano course and injures a
finger, thus being unable to play the piano the rest of the semester. A student would be allowed to complete other courses being
taken concurrently.
• Hardship Withdrawals requested after the Friday immediately prior to the final week of the term or not processed by the end of the term
will be treated as a Retroactive Hardship Withdrawal.
o Retroactive Hardship Withdrawals will not be approved if the student has completed all course requirements such as a final
examination and/or a final project.
o Retroactive Hardship Withdrawals will not be approved for terms occurring more than six months prior to the time the request is
made.
• Please Note: Academic suspension (term or one year) or academic dismissal may only be reviewed through a grade appeal or hardship
withdrawal. The suspension or dismissal will not be overturned until the grade appeal or hardship withdrawal has been processed. (UWG
Faculty Handbook, Section 208.05)
• Refunds will be based on a proportional percentage determined by the number of calendar days completed along with the total number of
calendar days in a Semester. The unearned portion shall be refunded up to the 60% point in time. Withdraws after the 60% point in time
are not entitled to a refund of charges. The category of Hardship Withdrawal does not grant any special refunds or financial consideration.
What are examples of conditions that do not warrant a Hardship Withdrawal?
The following list is illustrative of invalid reasons for a Hardship Withdrawal.
• Poor performance in one or more courses
• Registration for the wrong course
• Failure to drop a course during the drop/add period
• Failure to withdraw by the published deadline using normal procedures
Steps for Requesting a Hardship Withdrawal
In steps 1-6 below, the Dean may designate an Associate or Assistant Dean to act on his/her authority. The Provost and Vice President for Academic
Affairs may designate the Associate Vice President for Academic Affairs to act on his/her authority.
1. The student completes the “Request for Hardship Withdrawal” form found online at http://www.westga.edu/vpaa/
index_5879.php. The student should be prepared to provide documented evidence to
substantiate the hardship being
claimed.
2. The student submits the completed Request for Hardship Withdrawal form and documented evidence to Health Services
(HS) or the Counseling Center (CC).
3. The HS or CC professional staff will interview the student, review the documented evidence, and recommend to support or
not support the request for Hardship Withdrawal. HS or CC professional staff will send the request form and a letter, which
explains the recommendation, as a confidential document to the appropriate unit within Academic Affairs, while retaining
the documented evidence in their confidential files.
• Undergraduate students with a declared major: The request form and recommendation letter will be sent to the
Dean of the College where the major department is housed.
• Undeclared students: The request form and recommendation letter will be delivered to the Dean of the Honors
College.
• Graduate students: The request form and recommendation letter will be sent to the Dean of the College where
the graduate program is housed.
4. The Dean has the authority to approve the Request for Hardship Withdrawal. If the Dean approves the request, the Dean’s
Office will notify the student of the approval and communicate with the Registrar to change the grade/s to W.
5. If the Dean does not approve the request, the Dean’s Office will notify the student of the denial. The student may then
request a review by the Provost. It is the student’s responsibility to notify the Dean that he or she wants the Provost review
to be done. When notified by the student, the Dean will forward the request form and recommendation letter to the
Provost.
6. The Provost has the final authority to grant the Request for Hardship Withdrawal. If the Provost approves the request, the
student will receive a W for each course. The Provost’s Office will notify the student that the request was approved and
communicate with the Registrar to change the grade/s to W. If the Provost denies the request, the Provost’s Office will
notify the student of the denial. The Request for Hardship Withdrawal ends with the Provost.
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Retroactive Hardship Withdrawal Form RevDec2018 Fillable Request for Hardship Withdrawal

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Completed 16 March 2020

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