UNIVERSAL COLLEGE LANKA

MITIGATING CIRCUMSTANCES (MC) FORM

You should submit this form to UCL Academic Administration and Student Support. Failure to
complete all sections of this form may result in rejection by the EC committee.

Submission of a MC claim does not automatically grant the approval of the claim until the claim has
been approved by the Program Coordinator.

SECTION A: To be completed by the student.

Name:

Student ID:

Contact Number:

Email:

Programme:

Intake:

SECTION B: To be completed by the student.

List only those modules for which you are claiming extenuating circumstances. You must complete all
of the boxes for each module affected.

Module Module Title Module Lecturer Assessment Type Original Actual Signature
Code (Assignment, Due Date Submissio of the
Exam). State all n Date module
assessments lecturer
affected for each
module

I declare that the information and evidence provided in Section B is true, complete and accurate. I
hereby give consent for UCL to contact the person or organization named in any supporting
documentation to confirm/clarify the information provided for EC consideration. I understand that
details of this claim will remain confidential to the panel except in certain circumstances detailed in
the procedure.

I am aware that submission of this form does not automatically grant approval of my claim unless
approval has been granted.

Signed: Date:
SECTION C: Details of your claim (To be completed by the student)

Please give brief details of your circumstances. (Attach a separate sheet, if space is not sufficient.)

SECTION D: Non-Supporting Evidence. (To Be Completed Only If Unable to Provide Evidence)

This section to be completed by your Programme Coordinator, Module Lecturer or other independent suitably
qualified person.

Name:

Position:

Contact Address:

Telephone Number:

Supporting Statement: (If the circumstance covers more than one module/course component, part D need only
be competed once. Please provide a brief outline of the extent to which, in your professional judgment, the
student was/will be affected by the circumstances and the dates to which his/her circumstances apply.)

Signature: Date:

OFFICE USE

MC Panel Decision: Upheld Rejected Deferred

Reason for decision:

Signature: Date:
SECTION E: Receipt to be returned to students.

Student name & Student No

Programme:

Date received:

Staff name / signature

I acknowledge & official
receipt of stamp Mitigating Circumstance Form
the completed