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Private Confidential PROFESSIONAL OPINION FORM Information in this form must be provided by a professional authority e.g. doctor counsellor nurse chaplain garda examination officer tutor who then stamps and signs the form. A Professional Authority is regarded for the purposes of this form as any professional individual who has dealt professionally with the student submitting the PC1 form and is aware of the personal circumstances leading to the student s appeal to the Examinations Board of the DIT. To the professional providing an opinion Your help in providing information regarding the student s situation is appreciated* This information will assist the Institute in the assessment of the student s academic performance. Please confirm that you have reviewed the students PC1 form* STUDENT S NAME Please indicate the category that best describes his/her circumstances. Physical Injury Illness accident or hospitalisation Family Illness Bereavement Other Personal or emotional Circumstances Victim of Crime Other DATE S ON WHICH STUDENT WAS SEEN DATE S OF ILLNESS/ACCIDENT/OTHER YOUR OPINION OF THE PERIOD DURING WHICH THE STUDENT WAS AFFECTED BY THE ABOVE CIRCUMSTANCES Please tick appropriate box NO EFFECT MODERATE UNABLE TO MAKE A JUDGEMENT I have reviewed the students PC1 form MILD SEVERE Yes / No NAME PROFESSION SIGNATURE DATE STAMP. To the professional providing an opinion Your help in providing information regarding the student s situation is appreciated* This information will assist the Institute in the assessment of the student s academic performance. Please confirm that you have reviewed the students PC1 form* STUDENT S NAME Please indicate the category that best describes his/her circumstances. Please confirm that you have reviewed the students PC1 form* STUDENT S NAME Please indicate the category that best describes his/her circumstances. Physical Injury Illness accident or hospitalisation Family Illness Bereavement Other Personal or emotional Circumstances Victim of Crime Other DATE S ON WHICH STUDENT WAS SEEN DATE S OF ILLNESS/ACCIDENT/OTHER YOUR OPINION OF THE PERIOD DURING WHICH THE STUDENT WAS AFFECTED BY THE ABOVE CIRCUMSTANCES Please tick appropriate box NO EFFECT MODERATE UNABLE TO MAKE A JUDGEMENT I have reviewed the students PC1 form MILD SEVERE Yes / No NAME PROFESSION SIGNATURE DATE STAMP. To the professional providing an opinion Your help in providing information regarding the student s situation is appreciated* This information will assist the Institute in the assessment of the student s academic performance. Please confirm that you have reviewed the students PC1 form* STUDENT S NAME Please indicate the category that best describes his/her circumstances. Physical Injury Illness accident or hospitalisation Family Illness Bereavement Other Personal or emotional Circumstances Victim of Crime Other DATE S ON WHICH STUDENT WAS SEEN DATE S OF ILLNESS/ACCIDENT/OTHER YOUR OPINION OF THE PERIOD DURING WHICH THE STUDENT WAS AFFECTED BY THE ABOVE CIRCUMSTANCES Please tick appropriate box NO EFFECT MODERATE UNABLE TO MAKE A JUDGEMENT I have reviewed the students PC1 form MILD SEVERE Yes / No NAME PROFESSION SIGNATURE DATE STAMP.

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  • Examinations
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