Self-declaration for Academic Accommodations
Student Signature: Date:
Please use this form to request deferrals for any missed course work.
Requests dealing with midterm exams, assignments or other term work should be sent to your instructor.
Requests dealing with nal exams should be sent to the Registrars Oce with a deferral application (
Please complete in full.
Registrars Oce
300 Tory Building, 1125 Colonel By Drive, Ottawa, ON, K1S 5B6
fax: (613) 520-4410
tel: (613) 520-3500
By subming this form, you acknowledge that you have read the following privacy noce.
Student name: Student number:
Carleton email address: Telephone:
Date(s) of missed course component (exam, assignment, course work): Date of Onset:
Anticipated Date of Recovery:
Nature of issue (Optional):
ex. cold, fever, self-isolation, personal health concern or other
Please indicate the impacted course(s):
Declaration (please read and check each box):
I certify that I missed the scheduled course component(s) listed above for the reason provided. I understand and acknowledge that providing
false or misleading information in order to avoid or delay the submission of work or to avoid an exam is a violation of section VI.4 of the Academic
Integrity Policy and a formal Academic Integrity investigation will be launched.
I am using this form as a self-declaration that I was unable to complete the scheduled course components listed above.
I am conrming that I am notifying the Instructor or applying for a deferral of a nal exam as soon as I was able.
I understand that deferring the course components listed above may result in a negative impact to my academic performance. I will consult with
an academic advisor as needed and be sure that I am aware of the academic withdrawal deadline and, as always, assess my continuation in my
courses before that deadline.
Oce Use Only
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