SOGN OG FJORDANE FYLKESKOMMUNE Måløy vidaregåande skule 6718 Deknepollen Søknad om særskild tilrettelegging ved eksamen NB: UTFYLLT SKJEMA LEVEVAST KONTORET FOR REGISTRERING Namn: __________________________________________________________________ Klasse:____________________ Fag : _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Type tiltak og tilrettelegging: 1. ___________________________________________________________________________________ 2. ___________________________________________________________________________________ 3. ___________________________________________________________________________________ Underskrift av elev: _________________________________________________dato:___________________ Underskrift av føresatt: _______________________________________________dato: __________________ Uttale frå faglærar/kontaktlærar: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Dokumentasjon: □ IOP / Mappe □ Legeattest (legg ved) □ Anna _____________________________________ __________________________________________________________________________________________ Dato: ________________ Underskrift av faglærar/kontaktlærar:_____________________________________ Vedtak: Søknaden er / er ikkje innvilga. Tiltak: ____________________________________________________________________________________ _____________________________________________________________________________________ Dato: __________________ Underskrift : ________________________________________________________
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