Request for an Incomplete Grade

First Name

Last Name

UVA Email Address

Full email, including @virginia.edu

Course Subject and Number (e.g. LPPP 5540-002)

Name of Instructor

Instructor UVA Email

Full email, including @virginia.edu

Reason for Requesting Incomplete Grade

Short Description of Work to be Completed

Proposed Completion Date

Do you have additional work to complete for this course?

YesNo

Short Description of Additional Work to be Completed

Proposed Completion Date for Additional Work

Student acknowledges that once an extension of time has been approved all work must be completed within 30 days from the end of the semester’s examination period for undergraduate students and within 200 days for graduate students. After this time, the grade will automatically convert to an “F”.