OSB Medical Certificate - uwindsor.ca · Student Medical Certificate 1 Faculty of Nursing Student Instructions: Once this form is completed by you and your Physician/Nurse Practitioner,

STUDENT MEDICAL CERTIFICATE

PART A: To be completed by THE STUDENT:

Student Number: ______________________

I, __________________________, hereby authorize Dr. __________________________ to provide the following

information to the Odette School of Business at the University of Windsor as it applies to my course of study and, if

required, to supply additional information, relating to my appeal for special academic consideration.

____________________ ____________________ ____________________ Signature Witness Date

PART B: To be completed by THE PHYSICIAN: I hereby certify that the above student was seen in Medical & Health Services for assessment and treatment. On the

basis of that visit (or those visits), I am providing the following information for evaluation to the Odette School of

Business.

1. What is the diagnosis [in broad terms] of the medical problem that would have impacted upon this student’s

course of study? ___________________________________________________________________________________________ 2. Is this an acute or chronic problem? ___________________________________________________________________________________________

3. Dates during which there were claims to have been affected by this problem (or acute episode if the problem

was chronic). ___________________________________________________________________________________________ 4. Dates seen/treated by physician. ___________________________________________________________________________________________

5. In what way was this student affected by this problem to impair their ability to study/prepare for or attend

their examinations? ___________________________________________________________________________________________ ___________________________________________________________________________________________

6. If this student is permitted to continue their course of study, is the medical problem likely to recur and affect

their studies again? If yes, please explain the severity of the affect on this student’s studies. ___________________________________________________________________________________________ ___________________________________________________________________________________________

____________________ ____________________ ____________________ Physician Name Signature Date

Office Stamp

reneewintermute

Typewritten Text

reneewintermute

Typewritten Text

Appendix A

reneewintermute

Typewritten Text

reneewintermute

Typewritten Text

Student Medical Certificate Faculty of Science – Department of Economics

This form has been adapted, with permission, from the University of Windsor Faculty of Law Student Medical Certificate and the University of Western Ontario Student Medical Certificate.

A. TO BE COMPLETED BY THE STUDENT: I, ____________________________ , hereby authorize Dr. ______________________________ to provide the following information to the University of Windsor and, if required, to supply additional information to support my request for special academic consideration for medical reasons. My personal information is being collected under the authority of the University of Windsor Act 1962 and will be used for administrative and academic record-keeping, academic integrity purposes, and the provision of services to students. For questions in connection with the collection of this information, the Associate Dean of my Faculty may be contacted at 519-253-3000. ________________________________ ___________________ ___________________ Signature Student No. Date B. TO BE COMPLETED BY THE PHYSICIAN: 1. I hereby certify that I provided health care services to the above-named student on _________________________________________. (insert date(s) student seen in your office/clinic) 2. The student could not reasonably be expected to complete academic responsibilities for the following reason (in broad terms): ____________________________________________________________________________ 3. This is an acute / chronic problem for this student. 4. Date(s) student affected by this problem: ______________________________________________ 5. Unable to complete academic responsibilities for: 24 hours 2 days 3 days 4 days 5 days Other (please indicate) _________________________ 6. Is the medical problem likely to recur and affect his/her studies again? Yes No Reason: _______________________________________________________________________ PHYSICIAN VERIFICATION Name: (please print) _____________________________ Registration No. ________________________ Signature: ______________________________________ Telephone No. ________________________ Address: ___________________________________________________________________________ (stamp, business card, or letterhead acceptable) Date ______ ___________________________ PLEASE RETAIN COPY FOR THE PATIENT’S CHART. Note: Cost of certificate to be paid by student. _________________________________________________________________________________________ The professor reserves the right to reject this certificate. Office Use: Date received ________________ Approved __________ Rejected ____________ Notified by email _________________

Student Medical Certificate 1 Faculty of Arts & Social Sciences

A. TO BE COMPLETED BY THE STUDENT: I, ____________________________ , hereby authorize Dr. ______________________________ to provide the following information to the University of Windsor and, if required, to supply additional information to support my request for special academic consideration for medical reasons. My personal information is being collected under the authority of the University of Windsor Act 1962 and will be used for administrative and academic record-keeping, academic integrity purposes, and the provision of services to students. For questions in connection with the collection of this information, the Associate Dean of my Faculty may be contacted at 519-253-3000, ext. 2029. ________________________________ ___________________ ___________________ Signature Student No. Date B. TO BE COMPLETED BY THE PHYSICIAN: 1. I hereby certify that I provided health care services to the above-named student on _________________________________________. (insert date(s) student seen in your office/clinic)

2. The student could not reasonably be expected to complete academic responsibilities for the following

reason (in broad terms understandable by a layperson): ____________________________________________________________________________ ____________________________________________________________________________

3. This is an acute and/or chronic problem for this student. 4. Date(s) during which student claims to have been affected by this problem:

_________________________ until _____________________________________________ 5. Unable to complete academic responsibilities for:

1 day 2 days 3 days 4 days 5 days Other (please indicate) _________________________

6. If the student is permitted to continue his/her course of study, is the medical problem likely to recur and affect his/her studies again? Yes No

Reason: ___________________________________________________________________________

PHYSICIAN VERIFICATION Name: (please print) _____________________________ Registration No. ________________________ Signature: ______________________________________ Telephone No. _________________________ Address: _________________________________________________________________________________ (stamp, business card, or letterhead acceptable) PLEASE RETAIN COPY FOR THE PATIENT’S CHART. Note: Cost of certificate to be paid by student.

1 This form has been adapted, with permission, from the University of Windsor Faculty of Law Student Medical Certificate and the University of Western Ontario Student Medical Certificate.

Student Medical Certificate 1 Faculty of Nursing

Student Instructions: Once this form is completed by you and your Physician/Nurse Practitioner, please submit the ORIGINAL to the Faculty of Nursing Main Office, 3rd Floor Toldo Building. Note: you are responsible for any costs associated with completion of this certificate.

A. TO BE COMPLETED BY THE STUDENT: I, ____________________________ , hereby authorize Dr./Mr./Ms ______________________________ to provide the following information to the University of Windsor and, if required, to supply additional information to support my request for special academic consideration for medical reasons. My personal information is being collected under the authority of the University of Windsor Act 1962 and will be used for administrative and academic record-keeping, academic integrity purposes, and the provision of services to students. For questions in connection with the collection of this information, the Associate Dean of my Faculty may be contacted at 519-253-3000, x2258. ________________________________ ___________________ ___________________ Signature Student No. Date (yy/mm/dd) B. TO BE COMPLETED BY THE PHYSICIAN/NURSE PRACTITIONER:

1. I hereby certify that I provided health care services to the above-named student on _________________________________________. (insert date(s) student seen in your office/clinic)

2. The student could not reasonably be expected to complete academic responsibilities for the following reason (in broad terms): ____________________________________________________________________________

3. This is an acute / chronic problem for this student.

4. Date(s) during which student claims to have been affected by this problem:

___________________________________________________________________________________ 5. Unable to complete academic responsibilities for:

24 hours 2 days 3 days 4 days 5 days Other (please indicate) _________________________


Reason: ___________________________________________________________________________

7. If the student is permitted to continue his/her course of study, are there any accommodations, restrictions or special conditions that need to be followed? Yes No

If yes, provide details: _________________________________________________________________

PHYSICIAN/NURSE PRACTITIONER VERIFICATION Name: (please print) _____________________________ Registration No. ________________________ Signature: ______________________________________ Telephone No. _________________________ Address: _________________________________________________________________________________ (stamp, business card, or letterhead required) PLEASE RETAIN COPY FOR THE PATIENT’S CHART. Note: Any costs associated with completion of certificate to be paid by student. 1 This form has been adapted, with permission, from the University of Windsor Faculty of Law Student Medical Certificate and the University of Western Ontario Student Medical Certificate. Rev 000 – 2009 08 31

Student Medical Certificate 1 Faculty of Arts and Social Sciences – School of Social Work

Student Instructions: Once this form is completed by you and your physician/nurse practitioner, you are to submit the ORIGINAL to your instructor. Note: you are responsible for any costs associated with the completion of this certificate.

A. TO BE COMPLETED BY THE STUDENT: I, ____________________________ , hereby authorize Dr. ______________________________ to provide the following information to the University of Windsor and, if required, to supply additional information to support my request for special academic consideration for medical reasons. My personal information is being collected under the authority of the University

of Windsor Act 1962 and will be used for administrative and academic record-keeping, academic integrity purposes, and the provision of services to students. For questions in connection with the collection of this information, the Associate Dean of my Faculty may be contacted at 519-253-3000. ________________________________ _______________________ _______________________ Signature Student No. Date Note to the student: This medical certificate, when completed by a physician, will be used by your instructor to determine whether you can receive consideration for a missed academic responsibility (e.g. missed final exam, class participation, assignment due date). This certificate, when completed, does not automatically excuse you from this academic responsibility. B. TO BE COMPLETED BY THE PHYSICIAN: 1. I hereby certify that I provided health care services to the above-named student on _______________________________. (insert date(s) student seen in your office/clinic)

2. The student could not reasonably be expected to complete academic responsibilities for the following reason (in broad

terms): ___________________________________________________________________________________________.

3. This is an acute / chronic problem for this student. 4. Date(s) the student was affected by this problem: _________________________________________________________. 5. Unable to complete academic responsibilities for:

24 hours 2 days 3 days 4 days 5 days

Other (please indicate) _________________________________________________________________________. 6. If the student is permitted to continue his/her course of study, is the medical problem likely to recur and affect his/her

studies again? Yes No Reason: ____________________________________________________________________________________. PHYSICIAN VERIFICATION Name: (please print) ____________________________________ Registration No. ___________________________ Signature: ____________________________________________ Telephone No. ____________________________ Address: ________________________________________________________________________________________

(stamp, business card, or letterhead is acceptable)

PLEASE RETAIN COPY FOR THE PATIENT’S CHART. Note: Cost of certificate to be paid by student.

The instructor reserves the right to reject this certificate. Office Use: Date received _______________ Approved __________ Rejected _________ Notified by email ____________

1 This form has been adapted, with permission, from the University of Windsor Faculty of Law Student Medical Certificate and the University of

Western Ontario Student Medical Certificate.

Student Medical Certificate 1 Faculty of Science Department of Earth and Environmental Sciences

A. TO BE COMPLETED BY THE STUDENT: I, ____________________________ , hereby authorize Dr. ______________________________ to provide the following information to the University of Windsor and, if required, to supply additional information to support my request for special academic consideration for medical reasons. My personal information is being collected under the authority of the University of Windsor Act 1962 and will be used for administrative and academic record-keeping, academic integrity purposes, and the provision of services to students. For questions in connection with the collection of this information, the Associate Dean of my Faculty may be contacted at 519-253-3000. ________________________________ ___________________ ___________________ Signature Student No. Date B. TO BE COMPLETED BY THE PHYSICIAN: 1. I hereby certify that I provided health care services to the above-named student on _________________________________________. (insert date(s) student seen in your office/clinic) 2. The student could not reasonably be expected to complete academic responsibilities for the following reason

(in broad terms): ____________________________________________________________________________

3. This is an acute / chronic problem for this student. 4. Date(s) during which student claims to have been affected by this problem:




Reason: ___________________________________________________________________________

PHYSICIAN VERIFICATION Name: (please print) _____________________________ Registration No. ________________________ Signature: ______________________________________ Telephone No. _________________________ Address: _________________________________________________________________________________ (stamp, business card, or letterhead acceptable) PLEASE RETAIN COPY FOR THE PATIENT’S CHART. Note: Cost of certificate to be paid by student. The professor reserves the right to reject this certificate. Office Use: Date Received Approved Rejected Notified by email


UNIVERSITY OF WINDSOR FACULTY of LAW

MEDICAL CERTIFICATE

STUDENT NUMBER: ________________ A. TO BE COMPLETED BY THE STUDENT:

I, ___________________________________, hereby authorize Dr_____________________________ to provide the following information to the University of Windsor and, if required, to supply additional information to support my request for special academic consideration for medical reasons. My personal information is being collected under the authority of the University of Windsor Act 1962 and will be used for administrative and academic record-keeping, academic integrity purposes, and the provision of services to students. For questions in connection with the collection of this information, the Associate Dean at the Faculty of Law may be contacted at 519.253.3000 Ext. 2923.

____________________ ___________________ ____________ Signature Witness Date

B. TO BE COMPLETED BY THE PHYSICIAN:

I hereby certify that the above student was seen in Medical & Health Services for assessment and treatment. On the basis of that visit, (or those visits) I am providing the following information for a petition to the Academic Status Committee in the Faculty of Law.

1. What is the Diagnosis [in broad terms] of the medical problem that would have impacted upon their course of study? ______________________________________________________________________________________________________ 2. Is this an acute or chronic problem for the student? _____________________________________________________________ 3. Dates during which the student claims to have been affected by this problem ( or acute episode if the problem was

chronic)._______________________________________________________________________________________________ 4. Dates seen in the clinic. __________________________________________________________________________________ 5. In what way was the student affected by the problem to impair their ability to study or prepare for examinations? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 6. If the student is permitted to continue their course of study, is the medical problem likely to recur and affect their studies again? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________

_______________________________________ __________________________

Physicians name (please print) Date _______________________________________ Signature Office Stamp

Student Medical Certificate 1 Faculty of Science – Department of Chemistry and Biochemistry

A. TO BE COMPLETED BY THE STUDENT: I, ____________________________ , hereby authorize Dr. ______________________________ to provide the following information to the University of Windsor and, if required, to supply additional information to support my request for special academic consideration for medical reasons. My personal information is being collected under the authority of the University of Windsor Act 1962 and will be used for administrative and academic record-keeping, academic integrity purposes, and the provision of services to students. For questions in connection with the collection of this information, the Associate Dean of my Faculty may be contacted at 519-253-3000. ________________________________ ___________________ ___________________ Signature Student No. Date B. TO BE COMPLETED BY THE PHYSICIAN: 1. I hereby certify that I provided health care services to the above-named student on _________________________________________. (insert date(s) student seen in your office/clinic) 2. The student could not reasonably be expected to complete academic responsibilities for the following

reason (in broad terms): ____________________________________________________________________________

3. This is an acute / chronic problem for this student. 4. Date(s) student affected by this problem: ________________________________________________ 5. Unable to complete academic responsibilities for:


6. Is the medical problem likely to recur and affect his/her studies again? Yes No

Reason: ___________________________________________________________________________

PHYSICIAN VERIFICATION Name: (please print) _____________________________ Registration No. ________________________ Signature: ______________________________________ Telephone No. _________________________ Address: _________________________________________________________________________________ (stamp, business card, or letterhead acceptable) Date ______ ___________________________ PLEASE RETAIN COPY FOR THE PATIENT’S CHART. Note: Cost of certificate to be paid by student. _________________________________________________________________________________________ The professor reserves the right to reject this certificate. Office Use: Date received ________________ Approved __________ Rejected ____________ Notified by email _________________


Student Medical Certificate 1 Faculty of Engineering

A. TO BE COMPLETED BY THE STUDENT: I, ____________________________ , hereby authorize Dr. ______________________________ to provide the

following information to the University of Windsor and, if required, to supply additional information to support my

request for special academic consideration for medical reasons. My personal information is being collected under the

authority of the University of Windsor Act 1962 and will be used for administrative and academic record-keeping,

academic integrity purposes, and the provision of services to students. For questions in connection with the collection

of this information, the Associate Dean of my Faculty may be contacted at 519-253-3000.

________________________________ ___________________ ___________________

Signature Student No. Date Note to the Student: This medical certificate, when completed by a physician, will be used by the Faculty of Engineering to determine whether you can receive consideration for a missed academic responsibility (e.g., missed final exam). This

certificate, when completed, does not automatically excuse you from this academic responsibility.

B. TO BE COMPLETED BY THE PHYSICIAN: 1. I hereby certify that I provided health care services to the above-named student on

_________________________________________. (insert date(s) student seen in your office/clinic)

2. The student could not reasonably be expected to complete academic responsibilities for the following reason

(in broad terms).

____________________________________________________________________________ Note to the Attending Physician: Generic descriptions without explanations such as "unfit for study/exam" will be rejected by the Faculty of Engineering. All information provided on this form is held in confidence.



___________________________________________________________________________________

5. Unable to complete academic responsibilities for: 24 hours 2 days

3 days 4 days 5 days Other (please indicate) _________________________

6. If the student is permitted to continue his/her course of study, is the medical problem likely to recur and

affect his/her studies again? Yes No

Reason: ___________________________________________________________________________

PHYSICIAN VERIFICATION Name: (please print) _____________________________ Registration No. ________________________

Signature: ______________________________________ Telephone No. _________________________

Address: _________________________________________________________________________________

(stamp, business card, or letterhead acceptable)


1 This form has been adapted, with permission, from the University of Windsor Faculty of Law Student Medical Certificate and the University of Western

Ontario Student Medical Certificate. Faculty of Engineering 08Sep2009-Ver1.0

Student Medical Certificate 1 Faculty of Human Kinetics

A. TO BE COMPLETED BY THE STUDENT: I, ____________________________ , hereby authorize Dr. ______________________________ to provide the following information to the University of Windsor and, if required, to supply additional information to support my request for special academic consideration for medical reasons. My personal information is being collected under the authority of the University of Windsor Act 1962 and will be used for administrative and academic record-keeping, academic integrity purposes, and the provision of services to students. For questions in connection with the collection of this information, the Department Head of Kinesiology may be contacted at 519-253-3000. ________________________________ ___________________ ___________________ Signature Student No. Date B. TO BE COMPLETED BY THE PHYSICIAN: 1. I hereby certify that I provided health care services to the above-named student on _________________________________________. (insert date(s) student seen in your office/clinic)







Reason: ___________________________________________________________________________


1 This form has been adapted, with permission, from the University of Windsor Faculty of Law Student Medical Certificate and the

University of Western Ontario Student Medical Certificate.

STUDENT MEDICAL CERTIFICATE

PART A: To be completed by THE STUDENT:

Student Number: ______________________

I, __________________________, hereby authorize Dr. __________________________ to provide the following

information to the Odette School of Business at the University of Windsor as it applies to my course of study and, if

required, to supply additional information, relating to my appeal for special academic consideration.

____________________ ____________________ ____________________ Signature Witness Date

PART B: To be completed by THE PHYSICIAN: I hereby certify that the above student was seen in Medical & Health Services for assessment and treatment. On the

basis of that visit (or those visits), I am providing the following information for evaluation to the Odette School of

Business.

1. What is the diagnosis [in broad terms] of the medical problem that would have impacted upon this student’s

course of study? ___________________________________________________________________________________________ 2. Is this an acute or chronic problem? ___________________________________________________________________________________________

3. Dates during which there were claims to have been affected by this problem (or acute episode if the problem

was chronic). ___________________________________________________________________________________________ 4. Dates seen/treated by physician. ___________________________________________________________________________________________

5. In what way was this student affected by this problem to impair their ability to study/prepare for or attend

their examinations? ___________________________________________________________________________________________ ___________________________________________________________________________________________

6. If this student is permitted to continue their course of study, is the medical problem likely to recur and affect

their studies again? If yes, please explain the severity of the affect on this student’s studies. ___________________________________________________________________________________________ ___________________________________________________________________________________________

____________________ ____________________ ____________________ Physician Name Signature Date

Office Stamp




request for special academic consideration for medical reasons. My personal information is being collected

under the authority of the University of Windsor Act 1962 and will be used for administrative and academic

record-keeping, academic integrity purposes, and the provision of services to students. For questions in

connection with the collection of this information, the Associate Dean of my Faculty may be contacted at 519-

253-3000, ext. 2029.

________________________________ ___________________ ___________________ Signature Student No. Date B. TO BE COMPLETED BY THE PHYSICIAN: 1. I hereby certify that I provided health care services to the above-named student on _________________________________________. (insert date(s) student seen in your office/clinic)







Reason: ___________________________________________________________________________









connection with the collection of this information, the Department Head of Kinesiology may be contacted at 519-

253-3000.








Reason: ___________________________________________________________________________





Student Instructions: Once this form is completed by you and your Physician/Nurse Practitioner, please submit the ORIGINAL to the Faculty of Nursing Main Office, 3

rd Floor Toldo Building. Note: you are responsible for any costs associated with

completion of this certificate.

A. TO BE COMPLETED BY THE STUDENT: I, ____________________________ , hereby authorize Dr./Mr./Ms ______________________________ to

provide the following information to the University of Windsor and, if required, to supply additional information to

support my request for special academic consideration for medical reasons. My personal information is being

collected under the authority of the University of Windsor Act 1962 and will be used for administrative and

academic record-keeping, academic integrity purposes, and the provision of services to students. For questions in

connection with the collection of this information, the Associate Dean of my Faculty may be contacted at 519-253-

3000, x2258.

________________________________ ___________________ ___________________ Signature Student No. Date (yy/mm/dd) B. TO BE COMPLETED BY THE PHYSICIAN/NURSE PRACTITIONER:








Reason: ___________________________________________________________________________



PHYSICIAN/NURSE PRACTITIONER VERIFICATION Name: (please print) _____________________________ Registration No. ________________________ Signature: ______________________________________ Telephone No. _________________________ Address: _________________________________________________________________________________ (stamp, business card, or letterhead required)

PLEASE RETAIN COPY FOR THE PATIENT’S CHART. Note: Any costs associated with completion of certificate to be paid by student.


Western Ontario Student Medical Certificate. Rev 000 – 2009 08 31

Student Medical Certificate 1 Faculty of _______________







253-3000.








Reason: ___________________________________________________________________________






(in broad terms): ____________________________________________________________________________





Reason: ___________________________________________________________________________










253-3000, ext. 2029.








Reason: ___________________________________________________________________________









Reason: ___________________________________________________________________________







MEDICAL CERTIFICATE








_______________________________________ __________________________




A. TO BE COMPLETED BY THE STUDENT: I, ____________________________ , hereby authorize Dr. ______________________________ to provide the following

information to the University of Windsor and, if required, to supply additional information to support my request for special

academic consideration for medical reasons. My personal information is being collected under the authority of the University

of Windsor Act 1962 and will be used for administrative and academic record-keeping, academic integrity purposes, and the

provision of services to students. For questions in connection with the collection of this information, the Associate Dean of my

Faculty may be contacted at 519-253-3000.

________________________________ _______________________ _______________________ Signature Student No. Date Note to the student: This medical certificate, when completed by a physician, will be used by your instructor to determine whether you can receive consideration for a missed academic responsibility (e.g. missed final exam, class participation, assignment due date). This certificate, when completed, does not automatically excuse you from this academic responsibility. B. TO BE COMPLETED BY THE PHYSICIAN: 1. I hereby certify that I provided health care services to the above-named student on _______________________________. (insert date(s) student seen in your office/clinic)


terms): ___________________________________________________________________________________________.

















________________________________ ___________________ ___________________






(in broad terms).




___________________________________________________________________________________





Reason: ___________________________________________________________________________



Address: _________________________________________________________________________________












253-3000, ext. 2029.








Reason: ___________________________________________________________________________









connection with the collection of this information, the Department Head of Kinesiology may be contacted at 519-

253-3000.








Reason: ___________________________________________________________________________





Student Instructions: Once this form is completed by you and your Physician/Nurse Practitioner, please submit the ORIGINAL to the Faculty of Nursing Main Office, 3

rd Floor Toldo Building. Note: you are responsible for any costs associated with

completion of this certificate.

A. TO BE COMPLETED BY THE STUDENT: I, ____________________________ , hereby authorize Dr./Mr./Ms ______________________________ to

provide the following information to the University of Windsor and, if required, to supply additional information to

support my request for special academic consideration for medical reasons. My personal information is being

collected under the authority of the University of Windsor Act 1962 and will be used for administrative and

academic record-keeping, academic integrity purposes, and the provision of services to students. For questions in

connection with the collection of this information, the Associate Dean of my Faculty may be contacted at 519-253-

3000, x2258.

________________________________ ___________________ ___________________ Signature Student No. Date (yy/mm/dd) B. TO BE COMPLETED BY THE PHYSICIAN/NURSE PRACTITIONER:








Reason: ___________________________________________________________________________



PHYSICIAN/NURSE PRACTITIONER VERIFICATION Name: (please print) _____________________________ Registration No. ________________________ Signature: ______________________________________ Telephone No. _________________________ Address: _________________________________________________________________________________ (stamp, business card, or letterhead required)

PLEASE RETAIN COPY FOR THE PATIENT’S CHART. Note: Any costs associated with completion of certificate to be paid by student.


Western Ontario Student Medical Certificate. Rev 000 – 2009 08 31

Student Medical Certificate 1 Faculty of _______________







253-3000.








Reason: ___________________________________________________________________________






(in broad terms): ____________________________________________________________________________





Reason: ___________________________________________________________________________










253-3000, ext. 2029.








Reason: ___________________________________________________________________________









Reason: ___________________________________________________________________________







MEDICAL CERTIFICATE








_______________________________________ __________________________




A. TO BE COMPLETED BY THE STUDENT: I, ____________________________ , hereby authorize Dr. ______________________________ to provide the following

information to the University of Windsor and, if required, to supply additional information to support my request for special

academic consideration for medical reasons. My personal information is being collected under the authority of the University

of Windsor Act 1962 and will be used for administrative and academic record-keeping, academic integrity purposes, and the

provision of services to students. For questions in connection with the collection of this information, the Associate Dean of my

Faculty may be contacted at 519-253-3000.

________________________________ _______________________ _______________________ Signature Student No. Date Note to the student: This medical certificate, when completed by a physician, will be used by your instructor to determine whether you can receive consideration for a missed academic responsibility (e.g. missed final exam, class participation, assignment due date). This certificate, when completed, does not automatically excuse you from this academic responsibility. B. TO BE COMPLETED BY THE PHYSICIAN: 1. I hereby certify that I provided health care services to the above-named student on _______________________________. (insert date(s) student seen in your office/clinic)


terms): ___________________________________________________________________________________________.

















________________________________ ___________________ ___________________






(in broad terms).




___________________________________________________________________________________





Reason: ___________________________________________________________________________



Address: _________________________________________________________________________________





Documents

OSB Medical Certificate - uwindsor.ca · Student Medical Certificate 1 Faculty of Nursing Student Instructions: Once this form is completed by you and your Physician/Nurse Practitioner,