Form No: A4
INDIAN INSTITUTE OF TECHNOLOGY (INDIAN SCHOOL OF MINES) DHANBAD
OFFICE OF THE DEAN (ACADEMIC)
APPLICATION FORM FOR APPEARING IN THE MAKE-UP EXAMINATION
PART A (To be filled by the student)
Academic Session Semester MONSOON √ WINTER √
MAKE-UP EXAMINATION FOR: Mid Semester Examination √ End Semester Examination √
1. Name of Student
2. Admission No. Department
3. Program Branch (if any)
4. Institute Email ID
5. Contact Number
6. COURSE(S) FOR WHICH MID/END-SEMESTER EXAMINATION HAS BEEN MISSED:
Sl. Course Credits Title of the Course IC/DC/DP/DE/
No. Code OE/ESO
7. REASONS FOR MISSING MID/END SEMESTER EXAMINATION:
(Copy of the approved leave to be attached, if applicable. Part B of this form is also required to be submitted in case of absence due to
medical reasons. The student needs to fill part A and submit it to the doctor whom he/she consulted at Health Centre of this Institute.
The doctor will further submit it to CMO-IC of the Health Centre along with Part A and duly filled-in Part B)
Date:___________________ Time:__________________ Signature of the Student: _____________________________
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PART B (To be filled by the Doctor consulted at this Institute’s Health Centre)
In case of absence due to medical reasons, the student needs to fill part A and submit it to the doctor whom he/she consulted at Health Centre of
this Institute. The doctor will further submit it to the CMO-IC of the Health Centre along with Part A and duly filled-in Part B. The duly filled
in parts A & B of the form will be collected from the health centre by the Office of Dean (Acad)
1. Name of the Student
2. Date of Reporting of student at Health Centre
3. Time of Reporting of student at Health Centre
Came walking without any help ______
How did the Patient report to the Doctor? Came walking with help from others _________
4. (Whether came walking or brought on a
Came on a wheel chair ________
stretcher) Please Tick one.
Brought on a stretcher ________________
Brief Clinical
Notes &
5. Provisional/Dif
ferential
Diagnosis
Whether any Investigation/Diagnostic/
Pathological lab test/ Biopsy/Endoscopy etc.
YES / NO / Not Available
6. substantiates the problem reported by the patient
or the diagnosis?
(If yes, kindly attach a copy of the report provided)
When can this patient be advised to sit and write Now ________, After 30 mins to 1 hour _________,
an examination of 2-3 hours duration in the
exam hall? (Kindly tick one or provide a date, if After 2-3 hours_________, After 6-8 hours_______,
7.
possible, based on clinical features during
examination) from __________________Can’t be said_________
Whether the patient was kept under observation Kept under observation from______ to ________ /
8. in Health Centre or referred for admission to any
hospital? Referred for Admission on __________ /
If yes, date to be mentioned Not Admitted ___________
Has the patient been advised complete bedrest?
9. YES / NO
If yes, until what date? (subject to follow up
consultation if required by the patient)
If yes, until what date_______________
(THIS FORM HAS TO BE HANDED OVER BY THE DOCTOR TO THE CMO-IC OF THE HEALTH CENTER
WITH DULY FILLED-IN PART-A AND PART- B FOR HIS/HER ENDORSEMENT)
Name of the Doctor: _________________________Signature ______________ Date:__________
Signature of CMO-IC with remarks, if any_________________________________ Date:__________
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PART C (To be filled by the Office of Dean Academic)
Observations, if any:
Permission for appearing in Missed Mid/End-Semester
Examination is:
GRANTED: NOT GRANTED:
Date:_______________ __________________________ Specific remarks, if any:
Assistant Registrar (UG / PG)
(Signature)
………………………………………………………………………………………..………
Recommendation of the Assoc. Dean (UG/PG):
Based on the facts, as stated above, the application is:
Date:_______________ __________________________
RECOMMENDED/NOT RECOMMENDED Dean (Academic)
(Signature)
Specific remarks, if any:
Date:_______________ __________________________
Assoc. Dean (UG / PG)
(Signature)
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