Fillable Vocational Education And Swinburne Professional Special Consideration Application Form (Swinburne University of Technology)

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Vocational Education And Swinburne Professional Special Consideration Application Form (Swinburne University of Technology)

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Vocational Education and Swinburne Professional
Special Consideration
Author: Office Senior DVC and Provost Date last updated: 15 December 2017 Page 1 of 4
Purpose of this form
You can apply for special consideration if something out of the ordinary and beyond your control happens to you, and it impacts on your ability to complete an assessment task. You will be required to provide
documentation to support your application (e.g. Medical Impact Statement, Statutory Declaration, police report, etc.). For further information, visit the Special Consideration website
.
If your application for special consideration is based on medical grounds, you must submit a Medical Impact Statement (page 3 of this form) completed by your Professional Practitioner to support your
application.
Guidelines for Special Consideration
• The policy for special consideration is detailed in item 5.2 in the Assessment and Results Policy
• You may apply for special consideration if you have been:
- significantly hampered, by illness or other extraordinary causes, from preparing or presenting for an assessment task
- adversely affected by illness or other extraordinary causes, during the performance of an assessment task
• When your medical condition does not prevent you from attending or sitting an assessment task, you:
- must attend and sit the assessment task; and
- may apply for special consideration if you consider that you have grounds under the Academic Courses Regulation 44
.
• When a decision is being made about this application, the following will be considered:
- your performance in other assessment tasks in the unit and/or whether you have met all other requirements for successful completion of the unit
- the nature of the special circumstances
- the relevance, nature and authenticity of the evidence provided
- the requirements and any constraints of the particular assessment task
• The outcome of your application may be that you:
- are granted an extension to the due date for your assessment task
- are given special arrangements for your assessment task
- may be able to re-do one or more of your assessment tasks
- are not granted special consideration (a full reason will be provided).
Submission Details
• This application must be received no later than 5pm on the third working day after the submission date for the assessment task for which Special Consideration is being claimed.
• This form must be completed, scanned with supporting documentation and submitted via e-mail to VE-Progressions@swin.edu.au
• Late applications or applications that do not meet the documentation requirements as stipulated by the University may be deemed ineligible.
• E-mail VE-Progressions@swin.edu.au if you:
- are unable to submit the form by the deadline OR
- change your mind and wish to retract your special consideration application. You have two days to retract a special consideration application once lodged.
Vocational Education and Swinburne Professional
Special Consideration
Author: Office Senior DVC and Provost Date last updated: 15 December 2017 Page 2 of 4
Instructions for Students
1. Complete Sections A, B, D, E and include all supporting documentation.
2. Submit this application via e-mail to VE-Progressions@swin.edu.au
3. You will receive an outcome of this application within 10 working days in your Swinburne student email.
OFFICE USE ONLY
Date received:
Sent for Assessment:
Outcome received:
Student notified:
Section A – Student Details
Student ID
Surname Given Name
Mobile
Section B – Course and Unit Details Section C – Outcome
Course Code Course Title
Approved
New
Assessment
Due Date
Reason for Not Approved
Teacher
Signature
Unit Code Unit Title
Teacher Name Assessment Task Name
Assessment
Task Due
Date
Yes No
Section D – Reason for Special Consideration
☐
Medical Grounds
☐
Non-Medical
Grounds (please state reason):
☐
Supporting doc
umentation attached
Provide any further information to support your application for special consideration:
Section E – Student Declaration
I am applying for Special Consideration for the stated units of study and declare that the information I have provided in this
application and on the attached documentation is true and correct. Where a medical impact statement and/or supporting
documentation are attached, I authorise Swinburne University to seek information directly from the originating source.
Signature Date
This form must be completed by a Registered Practitioner
Students should note that submitting fraudulent medical documentation
could result in suspension or exclusion from the university.
Practitioner'sstamp
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
.
Regist
ere
d
Prac
titioner Detail
s
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.
Page 3 of 4
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This form must be completed by a Registered Practitioner
Students should note that submitting fraudulent medical documentation
could result in suspension or exclusion from the university.
Guideli
nes 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), Swinburne Health Services (for counselling and psychological services and general medical
treatment) and Student Financials (for financial assistance).
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.
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Completed 4 February 2021

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