Appendix M: Exam Make Up Petition Form

MOBERLY AREA COMMUNITY COLLEGE - HEALTH SCIENCE
STUDENT EXAM MAKE-UP PETITION FORM

Student Section: Students need to fill out this portion of the form. This petition must be submitted within one week of the exam or exam closing.

I, _________________________________, wish to petition the nursing faculty of Moberly Area Community College to schedule a make-up exam test date for the following exam, _____________________, given on the following date of my absence, ________________________.

My expected date of graduation is: ________________________.

I was absent due to the reason(s) outlined below, and supporting evidence accompanies this petition.

________________________________________________________________________________

Faculty Section: Faculty to complete this section of the form. ADN instructors submit a copy to the Health Science Director, the student, and place a copy in the student’s file. PN instructors submit a copy to the Practical Nursing Coordinator, the student, and place a copy in the student’s file.
We, the faculty, after careful consideration, have determined the student:

_____May take a makeup exam on ____________; the student will receive a _______% deduction based on

________________________________________________________________________________

Faculty Signatures

Health Sciences Dean/Director: ____________________________________________________

PN Coordinator: __________________________________________________________________

ADN Coordinator: _________________________________________________________________

Student Signature: ________________________________________________________________

Date: ___________________________________________________________________________