Application no. (to be filled by the HKEAA):

Hong Kong Examinations and Assessment Authority Hong Kong Diploma of Secondary Education Examination

Application for Exemption for School-based Assessment (SBA)

Part A School Information

School Code: School Name: Contact person: Tel.:

Part B Student Information

Our school would like to apply for SBA exemption for the student for the subject(s) and task(s) as specified below: Student Name (English) : (Chinese)

HKID Number: Examination Year:

Subject Tasks (please specify)

All S5 Tasks

All S6 Tasks

Partial Exemption, please specify the task(s)/item(s) (E.g. S5 Expt 1, S6 選修單元二, Eng Part A):

All S5 Tasks

All S6 Tasks

Partial Exemption, please specify the task(s)/item(s) (E.g. S5 Expt 1, S6 選修單元二, Eng Part A):

All S5 Tasks

All S6 Tasks

Partial Exemption, please specify the task(s)/item(s) (E.g. S5 Expt 1, S6 選修單元二, Eng Part A):

All S5 Tasks

All S6 Tasks

Partial Exemption, please specify the task(s)/item(s) (E.g. S5 Expt 1, S6 選修單元二, Eng Part A):

All S5 Tasks

All S6 Tasks

Partial Exemption, please specify the task(s)/item(s) (E.g. S5 Expt 1, S6 選修單元二, Eng Part A):

Justification(s)*:

*Please attach the supporting documents to this form (e.g. medical report(s), student’s attendance record, change of school record, etc). Please note that SBA exemption will only be considered with valid reasons and supporting documents. The HKEAA will notify schools of the application results within 1 month after the application is received.

Signature of School Principal: Date:

Name of School Principal: School Seal: