Request for Special Action Form

Revised 4/27/17

Request for Special Action Form

Last Name ______First Name______VID ______

Program ______Degree ______

Student’s VCU Email Address ______

□Change provisional admitstatus granted for academic reasons [AP] to full admit [AF]: sem/yr ______

[SATISFACTION OF ACADEMIC PROVISIONS MUST BE MET NO LATER THAN THE END OF TWELVE MONTHS AFTER MATRICULATION TERM.]

□ Change/Dropconcentration from ______to ______

Effective sem/yr ______

□ Add second concentration______effective sem/yr

□Change degree from ______to ______WITHIN SAME MAJOR

□ Add second degree ______effective ______sem/yr □ primary billing □ secondary billing

□ Student WILL complete and graduate from current program at end of sem/yr ______

and will begin new matriculation at beginning of sem/yr ______

□ Student WILLNOTcomplete/graduate from current program but will begin new matriculation on date indicated above.

□ Admit to graduate program that is restricted to direct student application online

Program______

Effective sem/yr______

□ Request approval for enrollment in a second degree/dual enrollment

New degree______

Effective sem/yr______

[APPROVAL FROM BOTH GPD AND GRADUATE SCHOOL REQUIRED.]

□Leave of Absence: from beginning of sem/yr ______through end of sem/yr ______

□Medical LOA, attach medical documentation. □Military LOA, attach copy of military orders or relevant documentation.

[LOA temporarily suspends continuous enrollment requirement but does not extend

time limit for completion of degree – 6 years for Certificates & Masters, 8 years ph.d.]

Leaves ofabsencecan affect Federal Direct Subsidized Loans and Direct Unsubsidized Loans repayments grace periods. Per the U.S. Department of Education, students have a six-month grace period before being required to begin repayment. Leaves greater than six months may initiate loan repayment.

□Early return from Leave of Absence: effective beginning of sem/yr ______[graduate school must re-open matriculation before student can register.]

□Extension of time limit for degree: from beginning of sem/yr ______through end of sem/yr ______

□Confirmall courses taken will still be relevant & current to discipline/curriculum by time student completes program. [ATTACH SUPPORTING DOCUMENTATION]

□CHECK BOX IF THIS IS TO BE FINAL EXTENSION & LIST ALL PREVIOUS APPROVED EXTENSIONS

Catalog Term: ______Overall time to degree if extension approved.______

from beginning of sem/yr ______through end of sem/yr ______

from beginning of sem/yr ______through end of sem/yr ______

□ Transfer of course work from other institutions, including course work taken under auspices of study abroad program at VCU

Institution / CRS Subject / CRS Number / Qtr/Sem Credit? / VCU Subject / VCU CRS Number / Degree Works Rule

□ If excess number of hours allowed by policy provide reason______

□ Is the student in a joint-dual, or collaborative- degree program with another university?

Participating Institution / Joint / Dual / Collaborative / VCU Awards Degree? / Total Degree Credit Hours

□ Confirm all transfer course requests have not been counted toward a previous degree, meets eligibility of credits policy and are or will still be relevant/current to discipline/curriculum when student graduates

□If in excess of time allowed by policy provide reason______

□ Re-pointing of VCU course(s)

Course designation(s) [i.e., ABCD 555]

CRN / SUBJECT / SECTION / CREDIT HOURS / GRADE / TERM

[Creditapplicableto ONE degree only unless student admitted to course of study

with defined number of shared courses.]

□Waiver of registration at VCU in semester of graduation

□Student approved by adviser/graduate program director to take course(s) at another institution: sem/yr______

□Other reason ______

□Confirm that student will not beusing university resources (i.e., library, advising, computers,etc.).

□ Add text comment to transcript: Degree requirements completed sem/yr ______

□Withdrawal from program for students in good academic standing: effective sem/yr ______

□Violation of Continuous Enrollment last attended ______sem/yr. □Other ______

Condition for future admission, if applicable______

[WITHDRAWAL FROM PROGRAM DOES NOT WITHDRAW STUDENT FROM COURSES. STUDENT MUST BE IN GOOD ACADEMIC STANDING TO BE CONSIDERED FOR PROGRAM WITHDRAWAL]

□Dismissal by program for cause: effective sem/yr ______

[Student will be officially notified by Graduate Dean via certified mail. Academic

dismissalnotation will be placed on student’s academic historY AND transcript.]

□Electronic DeliveryOnly

□ Academic performance □Exceeding time limit□Academic misconduct□Other ______

□Discontinuous enrollment □Honor policy violation □Professional misconduct ______

□Reinstate to ______program after successful appeal of termination effective ______sem/yr.

REGISTRATION ACTIONS:

□Registration of undergraduate student in 600-level or above course(s): sem/yr ______

Course designation(s) ______

□Undergraduate gpa ______(minimum 3.0 required)

□Student approaching last semester of study and will be applying to/has been accepted to graduate study at VCU or elsewhere

□Total number of hours enrolled ______(must not exceed 16 hours of combined credit)

[Credit applicable to ONLY ONE degree unlessstudent is admitted to course of study with

defined NUMBER OF shared courses.]

□Course overload: Number of credits (graduate & undergraduate, if applicable) ______sem/yr ______

[APPROVAL DOES NOT WAIVE PAYMENT OF ANY APPLICABLE COURSE OVERLOAD FEES.]

□ Add course(s) after add/drop deadline: sem/yr ______

Reason______

Course designation(s) & date student FIRST attended class(es) ______

______

ATTACH UES Course Request Form and documentation from instructor that confirms specific dates of attendance and

addresses circumstances of request.

□ Drop courses after add/drop deadline: sem/yr ______Reason ______

______

Course designation(s) & date student LAST attended class(es) ______

______

ATTACH UES Course Request Form, Financial Aid Impact of Retroactive and/or Mid-Semester Changes to Enrollment

Form, and documentation from instructor that confirms specific dates of attendance and addresses circumstances of request.

□ Withdrawal from courses(s) after withdrawal deadline: sem/yr ______

Reason ______

Course designation(s) & date student LAST attended class ______

______

[WITHDRAWAL DOES NOT REMOVE CHARGES.]

ATTACH UES Course Request Form, Financial Aid Impact of Retroactive and/or Mid-Semester Changes to Enrollment

Form, and documentation from instructor that confirms specific dates of attendance and addresses circumstances of request,

INCLUDING INFORMATION RE STUDENT’S PERFORMANCE IN COURSE(S)

[ ]IF THIS BLOCK IS MARKED, A HOLD HAS BEEN PLACED ON FUTURE REGISTRATIONS. STUDENT MUST

TAKE APPROVED FORM TO STUDENT ACCOUNTS TO COORDINATE PAYMENT/REGISTRATION. LATE

REGISTRATIONS WILL NOT BE POSTED/HOLDS WILL NOT BE LIFTED UNTILCHARGES ARE PAID.

***IN SOME CASES, STUDENT MAY BE REQUIRED TO RETURN PREVIOUSLY DISBURSED FINANCIAL AID.***

□ Late Grading

□ Missing/NR Grade □ Grade change due to error entry □ Late incomplete grade conversion

Reason ______

TERM / CRN / SUBJECT / COURSE / Section / Credits / Grade / Instructor

□ Incomplete Extension Request

TERM / CRN / SUBJECT / COURSE / Section / Credits

Reason ______

Coursework remaining to be completed and specific deadline dates for completion______

______

□OTHER ACTION ______

______

APPROVED COPIES WILL BE DISTRIBUTED BY EMAIL:

______

TYPE/PRINT: Graduate Program Director/Designee & VCU email addressSIGNATUREDATE

______

TYPE/PRINT: School Dean/Designee & VCU email addressSIGNATUREDATE

______

TYPE/PRINT: Graduate Dean/DesigneeSIGNATUREDATE

For Graduate School use only □ RR □ RR/GO □ SA □ FA □ OGE □GA