Personal Mitigating Circumstances Application Form (Salford Programmes)
Please complete ALL sections of this document as missing information may delay the processing of your application. Documentary evidence relating to your circumstances must be submitted along with this form.
Student DetailsName: / Student No:
Programme Title: / Occurrence: e.g. (15/16)
Personal Email Address: / Level:
Programme Leader: / Date:
Assessments affected by your Personal Mitigating Circumstances (PMC)
Type of Mitigation / An accepted PMC will result in…..
Late submission – you have submitted your work up to 4 working days after the deadline for submission of your assessment / An accepted PMC will result in removal of late submission penalties
Absence - absence from an examination, presentation, lab task, group task, etc. Also absence from classes where there is a minimum attendance rule. / An accepted PMC will result in a replacement attempt at the assessment in the next designated assessment period
Non-submission - work not submitted by the 4th working day after the submission deadline becomes a non-submission i.e. it cannot now be submitted / An accepted PMC will result in a replacement attempt at the assessment in the next designated assessment period
Title of module(s) affected / Assessment(s) affected / Date assignment set / Date of assessment/Due Date / Mitigation claimed for
Example: News Package Production / Example: Assignment 1 / Example:30 September 2013 / Example:13 December 2013 / Example: Non submission or absence or late submission
Your Circumstances
Please describe the nature of your personal mitigating circumstances and explain how they have affected your academic performance in the assessments above?
What steps are you taking (or have you taken) to minimise the effect on your work?
e.g. Action plans, liaison with tutors and HELMs
Student Declaration
I hereby confirm that the information is a true and accurate record and that I have read and understood the guidelines relating to Personal Mitigating Circumstances. I also consent to share any information held by other departments within the College which may support this application (i.e. Learning Support Records).
Student Signature: / Date:
For administration use only
Application Received by: / Application Complete: /
Received Date: / Documentary evidence attached: /
PMC Comments:
Review outcome:
First reviewer: / Signature: / Date:
Second reviewer: / Signature: / Date:
Student informed of outcome: /
Date: Click here / Nominated Tutor informed of outcome by e-mail: /
Date: Click here
Student Administration Manager
Return to: or HE Student Administration Manager, University Centre, Blackpool & The Fylde College, Bennett Avenue, Blackpool