R33 Form Faculty of Humanities and Social Sciences

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Student ID number (as per your student ID card)

First name

Surname

DCU email address

Programme of study/Qual Code (as per your Student ID card)

Year of study

Details of Examinations/Assessments Affected. To add more modules please click on the 'Add' button.

Module Code	Module Title	Operations
Module Code	Module Title

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	Please select the semester(s) affected by your extenuating circumstance(s)
	Semester 1 September to December
	Semester 2 January to April
	Resits July/August

Period affected from

Period affected to

Please note

If you have selected more than one period above, your supporting documentation should cover this period. Registry may contact you to confirm that your supporting documentation is up to date in advance of the resit period. It is the your responsibility to make sure that accurate supporting documentation is submitted to Registry within the published deadlines.

	Please tick the box below which best describes your extenuating circumstances
	Illness, injury, accident or hospitalisation.
	Family illness
	Bereavement
	Other personal or emotional circumstances
	Victim of crime
	Work commitments (Part-time students only)
	Other

R33 Rationale form: Postponement of Assessment

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Evidence of Program Chair approval

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If your R33 Rationale form does not contain a signature by your program chair, you should also attach a screenshot of email containing program chair approval.

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Supporting Documentation (e.g. medical certificates)

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I confirm that the information given in this form is true and factually correct. I understand that this information may be disclosed, where absolutely necessary, to academic and administrative staff of the University directly involved. I also consent to the processing of the special categories of personal data provided on this form for the purposes described in the Data Privacy Notice above.

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