VEC Sep 2024 - Fillable

Verification of Extenuating Circumstance Form
This confidential form verifies that the following student is experiencing an extenuating circumstance (e.g., illness, injury,
trauma, etc.) that temporarily impacts their ability to fulfill academic obligations and requirements.
Student Name: Student Number:
Queen’s Email: Phone Number:
Sec�on A: Authoriza�on to Share Informa�on - Completed by Student

I authorize the professional named below to complete this form. This form will be submited to the designated individual(s)
in my Faculty/School office and informa�on about dura�on and severity may be shared with instructors or university
personnel solely on a need-to-know basis.
Student Signature: Date:
Sec�on B: Verifica�on of Extenua�ng Circumstance - Completed by Professional

Impact on Academic Func�oning (all ques�ons must be answered)
Based on my professional assessment and working within my scope of prac�ce and responsibili�es, I confirm that this
student is experiencing an extenua�ng circumstance impac�ng their ability to fulfill academic obliga�ons.
1. Is the current extenua�ng circumstance related to an ongoing, persistent condi�on or disability? ☐Yes ☐No
2. If answered “yes” to Ques�on #1, please indicate if the student:
☐Is registered with Queen’s Student Accessibility Services (QSAS) for this condi�on or disability
☐Needs to register with QSAS for the first �me for this condi�on or disability
Please indicate the severity of the extenua�ng circumstance and the applicable start and an�cipated end dates of when
the student’s academics will be affected. Note that requests have a combined maximum of 12 weeks from start date
within the current term (Fall/Winter/summer): ☒check all that apply
Degree of Impact on Academic Func�on Start Date (d/m/y) An�cipated End Date
(d/m/y)
Severe / Serious Academic performance is seriously affected.
Student will require complete �me off from
their academic obliga�ons.
Mild / Moderate Due to extenua�ng circumstances the student
might require:
☐Occasional absences
☐Extra �me on assignments or other required
submissions
☐Alterna�ve arrangements for assessments
(tests, exams, etc.)
☐Alterna�ves to in class par�cipa�on
☐Group work (all listed arranged with the
instructor)
Addi�onal Comments:
Sec�on C: Professional’s Authoriza�on - Completed by Professional
Name: Profession/Posi�on:
Registra�on Number:
Signature: Date:
Contact # or Email: Department/Agency:
Revised September 2024

Information about the Verification of Extenuating Circumstance Form
Students are responsible for providing this documenta�on to their Faculty/School Office and contac�ng their individual
instructors to nego�ate academic considera�ons once documenta�on is processed. The final decision regarding the
academic considera�ons will be made by the course instructor.
Where can students go for addi�onal informa�on and assistance? If you require support while speaking with your
instructor, you are welcome to contact your Faculty/School Office for assistance. If you would prefer to speak with a health
care professional, you can connect with Student Wellness Services at (613) 533-2506.
Student Responsibilities
• Disseminate this form – see instruc�ons for individual Facul�es/Schools below. Follow the instruc�ons for the
Faculty/School that is gran�ng your degree:
• Arts and Science (including students studying at Bader College): Submit form to online portal:
htps://www.queensu.ca/artsci/undergrad-students/student-services/academic-considera�on-for-students.
• Smith Engineering: Submit forms at htps://qfeas.it/accom, for assistance email
[email protected]. A separate submission is needed if a final exam is missed. For absences that
are two weeks or longer, the students should pursue academic advising.
• Nursing (BNSc): Submit form (email or hard copy) to Barb Bolton (Rm 113).
• Educa�on (B.Ed): Submit form (email) to the B.ED Advisor, [email protected].
• Commerce: Submit a Request for Academic Considera�on for Extenua�ng Circumstances via the Commerce
Portal (htp://commerce.queensu.ca) and upload this form through the link provided by email. No hard copy
forms accepted.
• Law (JD Program): Submit form via email to law.accommoda�[email protected].
• Law (Cer�ficate in Law): Submit form via email to lawcer�fi[email protected].
• Medicine: Submit form (email or hard copy) to the Learner Wellness Centre.
• Occupa�onal Therapy: Submit form (email or hard copy) to your Program Assistant ([email protected]).
• Physical Therapy: Submit form (email or hard copy) to your Program Assistant
([email protected]).
• Bachelor of Health Sciences: Submit form using the Academic Considera�ons portal:
htps://considera�ons.bhsc.queensu.ca.
• Graduate Students: Submit this form (email or hard copy) to your Department/Program Graduate
Coordinator as soon as it becomes apparent that you are having difficulty mee�ng academic requirements
due to an extenua�ng circumstance.
Instructor Responsibilities
• Meet with the student to nego�ate academic considera�ons (i.e., deferral of tests/exams, extensions on
assignments, etc.)
• Assess missed academic obliga�ons and provide reasonable academic considera�ons, in good faith, while
maintaining essen�al academic requirements and standards
• Assure students who are experiencing an extenua�ng circumstance that reasonable academic considera�on will be
implemented, as appropriate, while ensuring essen�al academic requirements are met
Who can complete this form?

• A student services support professional (e.g., Chaplain, Sexual Violence Preven�on and Response Service Advisor,
Human Rights Office Advisor, etc.) with advanced training or educa�on.
• A health care provider at Student Wellness Services or in the community who is aware of your situa�on.
Revised September 2024

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Veriﬁcation of Extenuating Circumstance Form

Sec�on A: Authoriza�on to Share Informa�on - Completed by Student

Sec�on B: Veriﬁca�on of Extenua�ng Circumstance - Completed by Professional

Sec�on C: Professional’s Authoriza�on - Completed by Professional

Revised September 2024

Who can complete this form?

Revised September 2024

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