BSA - toetsingsverzoek / application form

Only applicable to firstyear Bachelor students. Applications submitted before the 1st of July of the current academic year will be considered.

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

Personal data


Study delay due to

A medical certificate of a Dutch doctor is required. Questions? Please contact

A medical certificate of a Dutch doctor or BIG-registered psychologist is required. Questions? Please contact

A birth cirtificate or medical certificate is required

A medical cirtificate of a Dutch doctor is required

if possible lodge with supporting certificates

deciscion on recognition Committee Topsports or Topculture required

requires a UC statement

requires a statement of the Association

In which period of time of the current academic year the circumstance took place? (dates need to be within the current academic year )

Upload the above-mentioned required documents

Explanation on your application

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? Speak in chronologic order of the modules.

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 a Study Adviser

Study delay should have been reported to your study adviser

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

When was the first appointment with your study advisor about your study delay or circumstances?

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

Have you got an adapted study plan?

Contact with Student Counsellor

An interview with a student counsellor is mandatory

Did you have an appointment with a student counsellor or have you already made an appointment?

The student counsellor you had or have an appointment with, is:

When was your (first) appointment with the student counsellor?

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

Read the information below carefully.

Cooperation CPO and SACC: The student counsellors are part of the department "Student Affairs, Coaching & Counselling" (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. 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.


The CPO does not share information with others without your permission! The CPO will seek advice from your study advisor during the processing of this application, because you are obliged to report the circumstances to your study advisor. Subsequently, study adjustments may be made or an adjusted study plan may be drawn up. The CPO advises the program board about your personal circumstances, but the program board decides on your BSA. It is advisable for your BSA and for possible help from your program that the CPO and your study advisor can share information.

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

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