Revised August 31
Verification of Confidential Extenuating Circumstance
This form is to verify a confidential extenuating circumstance that temporarily limits a student’s
academic participation or ability to meet academic requirements.
Student Name: _________________________
Student Number: ________________________
Queen’s Email: ________________________
Phone Number: __________________________
Section A: Authorization to Share Information - Completed by Student
I authorize the professional named below to complete this form in support of my request for academic considerations.
This form will be submitted to the designated individual(s) in my Faculty / School office and may be shared with
instructors or university personnel solely on a need to know basis.
Student Signature: _____________________________ Date: _____________________________
Section B: Verification of Confidential Extenuating Circumstance Completed by Professional
Based on my professional assessment I have determined that this student is experiencing an extenuating circumstance
that requires academic consideration. I have interacted with the student, reviewed documentation, and/or spoken with
reliable others, and have confidence that the extenuating circumstances are verifiable and are having an impact on the
student’s current ability to meet academic requirements. An assessment of the student’s functioning related to the specific
circumstance is within the scope of my professional practice. I believe that a confidential verification is in the best
interest of the student at this time.
Section C: Professional’s Authorization - Completed by Professional
Name: _______________________________ Profession / Position: _________________________________
Signature: _____________________________________ Date: ____________________________________
Contact # or Email: _____________________________ Department / Agency: _________________________
Limitations in Academic Functioning
Current impairment related to ongoing disability?
If yes, registered with Queen’s Student Accessibility Services (QSAS) for disability?
Yes No
If yes, do not complete this form. Send Letter of Accommodation to your instructor and contact QSAS, if needed.
Date of onset: _________________________
Anticipated duration of limitation (from date form completed):
< 1 wk 1 2 wks 2- 4 wks* 4 8 wks* 8- 12 wks* 12+ wks*
If the student’s limitation is currently serious or severe, improvement to mild or moderate limitation is expected
within < 1 wk 1 2 wks 2- 4 wks 4 8 wks 8- 12 wks
*I would recommend academic advising to further understand academic options available? Yes No
Due to health condition might require:
Occasional absences from classes, labs, placement
Extra time on assignments and/or thesis/dissertation obligation to be negotiated with
Rescheduling or other consideration for timed evaluations (i.e., unable to write tests,
quizzes, midterms, final exams)
Consideration may also be required for: In class participation Group work
Other: ______________________________________________________
Unable to fulfill all or most academic obligations.
Anticipated date student can communicate with instructors to develop an academic plan:
Date _____________________________ OR N/A (i.e., able to communicate now)
This student will require academic accommodations in order to complete quizzes/tests/exams (e.g., additional time
during tests/exams, smaller classroom for writing tests/exams, washroom breaks, etc.) No Yes
If yes, the student understands they will be required to connect with Student Wellness Services to discuss a short-term
academic accommodation plan (613.533.6000 X 74842). ______(Student Initials or N/A).
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Revised August 31
Information about the Verification of Confidential Extenuating Circumstance Form
Students are responsible for providing this documentation to their Faculty/School Office and contacting
their individual instructors to negotiate academic considerations once documentation is processed. The final
decision regarding the academic considerations will be made by the course instructor.
Where can students go for additional information and assistance?
If you require support while speaking with your instructor, you are welcome to contact your
Faculty/School Office for assistance. If you would prefer to speak with someone outside of your
Faculty/School, you can connect with Student Wellness Services. Please contact or 613.533.6000 X 74842.
Student Responsibilities
Disseminate this form see instructions for individual Faculties/Schools below. Follow the
instructions for the Faculty/School that is granting your degree.
Arts and Science (including students studying at BISC): Submit form to online portal.
Engineering & Applied Science: Submit forms at, for assistance email
Nursing (BNSc): Submit form (email or hard copy) to Barb Bolton (Rm 113)
Education (B.Ed): Submit form (email or hard copy) to Alan Wilkinson (Rm A101a)
Commerce: Submit a Request for Academic Consideration for Extenuating Circumstances
online on the Commerce Portal, under Academic Consideration. Submit this form (via
email) to No hard copy forms accepted.
Law: Submit form (email or hard copy) to Helen Connop (
Medicine: Submit form (email or hard copy) to the Learner Wellness Centre
Occupational Therapy: Submit form (email or hard copy) to your program assistant, Laurie
Kerr (
Physical Therapy: Submit form (email or hard copy) to Program Assistant Lindsey Morey
Bachelor of Health Sciences: Submit form electronically (email only) to the Bachelor of
Health Sciences Program Office (
Graduate Students: Submit form (email or hard copy) to your instructor(s) or supervisor
Instructor Responsibilities
Meet with student to negotiate academic considerations (i.e., deferral of tests/exams, extensions
on assignments, etc.)
Assess missed academic obligations and provide reasonable academic considerations, in good
faith, while maintaining essential academic requirements and standards
Assure students who are experiencing an extenuating circumstance that reasonable academic
consideration will be implemented, as appropriate, while ensuring essential academic
requirements are met
Who can complete this form?
A student services support professional (e.g., Chaplain, Sexual Violence Prevention and Response
Coordinator, Human Rights Office Advisor, etc.) or a health care provider at Student Wellness
Services or in the community who is aware of your situation can complete this form.