ID#                                                                                 Date:

NAME: 

COURSE #:       TITLE:

TERM:  -Select Term- Fall Spring J-Term Summer      YEAR:

The request for an Incomplete is to be student-initiated. It is granted ONLY on the basis of serious illness or similar extenuating circumstances that materially affects the student's ability to complete all requirements. An incomplete will not be granted solely on the basis of a student's needing more time. The incomplete MUST be cleared by mid-term of the next semester for continuing students or the "I" becomes an "F".

STUDENT INFORMATION

I am unable to complete requirements for the above course due to:
Illness   Accident   Death in Family   Other
which made it impossible to complete course work because

Student's Signature_____________________________________ Date  ___/___/___

INSTRUCTOR STATEMENT

I approve  dissaprove of this Incomplete grade request.

The extension of time requested would permit the student to complete work that may affect the overall evaluation. The extenuating circumstances described above were a factor in the student's inability to complete the work. I am able to supervise the completion of this work which I anticipate will be completed by: (Date)

Instructor's Signature_____________________________________ Date  ___/___/___

DEAN'S OFFICE ACTION

Dean's Signature_____________________________________ Date  ___/___/___