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Medicalform

The document is a student medical certificate used to request special academic consideration due to illness or injury. It contains sections for the student to authorize the release of medical information and for a licensed medical practitioner to assess the degree of incapacitation on the student's academic functioning, from severe to negligible. The practitioner must initial the most relevant category, provide details on visits related to the illness or injury, and verify the assessment is within their scope of practice by signing and providing contact information.

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38 views1 page

Medicalform

The document is a student medical certificate used to request special academic consideration due to illness or injury. It contains sections for the student to authorize the release of medical information and for a licensed medical practitioner to assess the degree of incapacitation on the student's academic functioning, from severe to negligible. The practitioner must initial the most relevant category, provide details on visits related to the illness or injury, and verify the assessment is within their scope of practice by signing and providing contact information.

Uploaded by

jbajaj9606
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Student Medical Certificate

(Submit to the Office of the Dean of the Student’s Home Faculty)

STUDENT NUMBER:
I. TO BE COMPLETED BY STUDENT:

I, (please print) ____________________, hereby authorize this licensed practitioner to


provide the following information to Western University and, if required, to supply additional information relating to my
petition for special academic consideration.

Signature Date

II. TO BE COMPLETED ONLY BY LICENSED PRACTITIONER: Please indicate the option below that applies, based on
examination and applicable documented history at the time of illness or injury, not after the fact.

Initial the most relevant Degree of Incapacitation on Academic Functioning Start Date Anticipated
category End Date
Completely unable to function at any academic level e.g.
Severe unable to attend classes, or fulfill any academic
obligations.
Significantly impaired in ability to fulfill academic
Serious obligations e.g. unable to complete an assignment,
unable to write a test/examination
May be able to fulfill some academic obligations but
Moderate performance considerably affected e.g. able to attend
some classes, decreased concentration, assignments
may be late.
Likely to be able to fulfill academic obligations, but
Mild performance affected to a minor degree, with mild
impairment and minimal symptoms.
Unlikely to have an effect on ability to fulfill academic
Negligible obligations.

 Describe when/how often you have seen the student with respect to the present illness/episode of illness/injury
Once – Visit Date:
Multiple/On-going – Visit Dates:

Additional Comments:

III. VERIFICATION BY LICENSED PRACTITIONER: I certify that this assessment falls within my legislated scope of practice.

_
NAME (please print) REGISTRATION No. CPSO

SIGNATURE DATE

ADDRESS (stamp, business card or letterhead acceptable) TELEPHONE #


Completion of this form does not guarantee that special consideration will be granted. Incomplete forms will not be processed.
In some appeal situations, the University may require additional information from you or your practitioner
to decide whether or not to grant or confirm special consideration.

PLEASE RETAIN COPY FOR THE PATIENT’S CHART.


NOTE: Any cost for this certificate must be paid by the patient.
Issued: 08SEP (Revised: 10DEC; 12JUN; 15JUN)

The personal information on this form is collected under the authority of the University of Western Ontario Act, 1982. The information is collected for the purpose of processing your request for academic
consideration. For further information about this collection, please contact the University Secretary, The University of Western Ontario, Stevenson Hall, Room 4101, London, ON N6A 3K7; Phone 519-661-
2055. For general inquires concerning this form, please contact the Office of the Dean of the student’s home faculty.

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