Application for assessment of circumstances

Personal data

Educational data

Study delay due to:

Period of time in the current academic year which the circumstance took place:
(date need to be within the current academic year)

Upload the above-mentioned required documents

Explanation of your personal circumstances

Please explain your personal circumstances below to clarify the application

What is the personal circumstance and what does it mean?

To what extent and in what way did the personal circumstances influence your studies?

What actions did you take to cope with the circumstances?

Did you have contact with healthcare providers from within or outside the UT because of the personal circumstances, or have you sought help in another way?

Contact with fainco or study adviser

Study delay should have been reported to your Fainco or study adviser. Did you have contact with your Fainco or study adviser about your circumstances?

The first appointment with your fainco/study advisor about the personal circumstances was/is on:

Have you drawn up an adapted study plan with your study adviser?

If you have not yet made contact your fainco/study advisor, please do as soon as possible.

Contact with student counsellor

An interview with a student counselor is mandatory.
Did you have an appointment with a student counsellor?

The study counsellor I have already spoken to is:

I had or have the first appointment with the student counselor on:

If you have not yet made an appointment with a student counsellor, you can make an appointment by calling the secretariat of Student Affairs Coaching & Counselling, phone +31 53 489 2035.

Permission to share data

Please read all of the information below.

The CPO does not share information with others without your permission

The CPO and student counselors are part of the department "Student Affairs, Coaching & Counseling" (SACC). The CPO and the student counselors work closely together. The CPO discusses data from this application with the student counselors in order to provide you good and complete support regarding MOMI and other regulation. By submitting this application, you automatically give permission to the CPO to discuss the contents of this application with the student counsellors.

The CPO will seek advice from your fainco/study advisor during the processing of this application, because you are obliged to report the circumstances to your fainco/study advisor as soon as reasonably possible. Subsequently, an adjusted study plan needs to be drawn up. The CPO advises the MOMI Committee about your personal circumstances, the MOMI Committee gives you the final notification regarding MOMI. It is advisable for your MOMi file and for possible help from your program that the CPO and your fainco/study advisor can share information.

I give permission to the CPO to share the contents of this application with my fainco/study advisor

I give permission to my fainco/study advisor to share information with the CPO.

Your request has been send to registry of the Committee Personal Circumstances.
In case of questions about the processing of your application, contact the registry at
phone +31 53 489 2403 or
phone +31 53 489 2254.