Application form BSA/MOMI

This application form is only applicable to first-year bachelor students, second-year students whose study advice is postponed or students with a residence permit for study purposes (MoMi students). Applications must be submitted before June 30 16:30 CET.

Your case will be dealt with confidentality. No data is shared unless you give permission. There will be no mention on your diploma of any matters that you discuss with a study adviser, a student counsellor or a student psychologist.

For which regulation do you want to submit an application:

BSA

MoMi

BSA and MoMi

Personal Data

Family name (last name)

Initials

Date of birth

UT E-mail

Student number (number only)

S

Study programme

Academic year in which you started this programme

Enrolled in

September

February

An appointment with a student counsellor is mandatory. If you haven't had or made an appointment with a student counsellor to discuss your personal circumstances in the past three months, please make an appointment as soon as possible by contacting the secretariat SACC: www.utwente.nl/en/ces/sacc/

Reason(s) for study delay

Study delay due to

Illness

A medical certificate of a Dutch BIG-registered doctor or a Dutch BIG-registered psychologist is required.

Psychological problems

A medical certificate of a Dutch BIG-registered doctor or a Dutch BIG-registered psychologist is required.

Physical, sensory or other dysfunction

A medical certificate of a Dutch BIG-registered doctor or a Dutch BIG-registered psychologist is required.

Exceptional family circumstances

You are advised to submit supporting statements or documents.

Pregnancy / delivery

A birth- and/or medical certificate is required.

Recognized board position. Name of the association:

(Student activism: membership of University Council, Faculty Council, Programme Committee or board as mentioned in FOBOS, appendix B, Cat. 3 and Cat. 4).

For BSA students: a statement of the association mentioning your position and the period you are/were in the board is necessary.

For MoMi students: submit a filled in MoMi activism form.

Insufficiently feasible study programme

Submit supporting statements or documents.

Top-level Sports or Top-level Arts

In case of Top-Level Sports or Top-Level Arts, a decision from Committee Topsports or Topculture is required.

Other causes which would result in extreme unfairness if a request for support would not be honored, namely:

Lodge with supporting certificates/statements

Period of circumstances

In which period of time of the current academic year did the circumstance(s) took place?

Starting (dd/mm/yyyy)

Until (dd/mm/yyyy)

Period of influence on study progress

In which period of the current academic year did the circumstance(s) influence your study progress?

Starting (dd/mm/yyyy)

Until (dd/mm/yyyy)

Documentation

Upload the above-mentioned required documents. For questions regarding the mentioned documents please send an e-mail to cpo@utwente.nl or discuss it with a student counsellor.

Explanation of circumstances

Please explain your personal circumstances below to clarify the application

What are the personal circumstances?

In what way did the personal circumstances influence your studies? Explain in chronologic order.

What actions did you take to cope with the circumstances?

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

Contact study adviser

Study delay due to personal circumstances should have been reported to your study adviser

Name of your study adviser

Did you have contact with your study adviser about your study delay or your personal circumstances?

Yes

No, because

When was the first appointment with your study adviser about your personal circumstances?

If you have not contacted your study adviser about the study delay yet, please contact your study advisor as soon as possible.

I'll make an appointment

Yes

No, because

Did you discuss your study plan with your study adviser?

Yes

No

Do you have an adapted study plan?

Yes

No

Contact student counsellor

An appointment with a student counsellor is mandatory. If you haven't had or made an appointment with a student counsellor to discuss your personal circumstances in the past three months, please make an appointment as soon as possible by contacting the secretariat SACC: www.utwente.nl/en/ces/sacc/

Have you had or made an appointment with a student counsellor?

Yes

No, because

With whom was your appointment?

Name student counsellor

Date on which you have or had an appointment with a student counsellor

Permission to share data

Please read all of the information below.

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

I have read the information above about the cooperation between the CPO and SACC

The CPO will seek advice from your study adviser during the processing of this application, because you are obliged to report the circumstances to your study adviser as soon as reasonably possible. Subsequently, an adjusted study plan needs to be drawn up.

It is advisable for your BSA and/or MOMI file and for possible help from your study programme that the CPO and your study adviser can share information.

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

Yes (advisable)

No, because

I give permission to my study adviser to share information with the CPO

Yes (advisable)

No, because

Final decision

In case of BSA, the CPO advises your study programme. Your study programme makes the final decision. More information about the procedure (including requesting a hearing) can be found here.
In case of MoMi, the CPO advices the MOMI Committee UT about your personal circumstances. The MOMI Committee UT informs you about the final decision.