Medical Statement - University of Ontario Institute of Technology

Medical StatementUniversity of Ontario Institute of Technology2000 Simcoe Street North, Oshawa, ON L1H 7K4 CanadaT: 905.721.3190www.uoit.caThere are two pages to the Medical Statement form. The student is required to complete Section A. The physician/counsellor is required toComplete Section B. The Medical Statement form must be completed, signed and dated by the treating physician no later than 24 hours afterthe scheduled examination. Both completed pages of this form are to be received by the appropriate UOIT office within five working days ofthe missed deadline or exam date.Please check the appropriate box () below to indicate the reason for completing this Medical Statement form.1) Deferred course work or final examinations• If a student missed course work because of incapacitating illness, the student must complete this Medical Statement form and submit itto the appropriate office within five working days of the missed deadline. The student should check the course syllabus to determine wherethe form should be submitted.• If a student missed a final examination because of incapacitating illness, the student may apply for a deferred exam. To apply for adeferred examination, a student must submit the request in writing by completing the Application for Deferred Examinations and thisMedical Statement form. The Medical Statement form must be completed, signed and dated by the treating physician no later than24 hours after the scheduled examination. Both forms must be submitted together to the appropriate faculty office within five workingdays of the missed examination. Faculties will only grant deferred examinations where sufficient documentation exists. If the student who isgranted an examination deferral does not write the exam by the scheduled deferred examination date, the permission will be withdrawn anda grade of zero will be recorded for the final examination.If this form is being submitted to a faculty office to support a request, the student can arrange to mail, scan and e-mail, or fax this MedicalStatement to the faculty responsible.* Please indicate which faculty should receive this form.◦ Faculty of Business and Information TechnologyE-mail: FBITadvising@uoit.caPhone: 905.721.8668 ext. 2830Fax: 905-721-3167◦ Faculty of Energy Systems and Nuclear ScienceE-mail: nuclear@uoit.caPhone: 905.721.8668 ext 2932Fax: 905.721.3046◦ Faculty of ScienceE-mail: science.advising@uoit.caPhone: 905.721.8668 ext. 2176Fax: 905.721.3304◦ Faculty of Criminology, Justice and Policy StudiesE-mail: CJPSadvising@uoit.caPhone: 905.721.8668 ext 3838Fax: 905.721.3372◦ Faculty of EducationE-mail: Faculty-Of-Education@uoit.caPhone: 905.721.3181Fax: 905.721.1707◦ Faculty of Engineering and Applied ScienceE-mail: engineering@uoit.caPhone: 905.721.8668 ext. 2971/2970Fax: 905-721-3370◦ Faculty of Health SciencesE-mail: HealthSciences@uoit.caPhone: 905.721.3166Fax: 905.721.3179◦ Graduate Studies officeE-mail: GradStudies@uoit.caPhone: 905.721.8668 ext. 2695Fax: 905.721.31192) Appeal requests: This Medical Statement may be used as a supplement to various appeal requests. This form must accompany the appealform it supports (fees, add/drop class etc.) and be completed by a physician/counsellor and submitted to the Registrar’s office along with allother required information.If this form is being submitted as a supplement to an appeal request, the student can arrange to mail, scan and e-mail (registration@uoit.ca), orfax (905.721.3178) this Medical Statement to the Registrar’s office.**Note to all students: If you scan and e-mail, or fax a document, you may be required to submit the original Medical Statement when you are well.Section A: To be completed by the studentLast name First name Student numberMyCampus e-mail addressProgramSpecial consideration is requested in the following course(s) or for the following deferred exam(s)*Course name and code(e.g. BIOL 1010U)Section Instructor or TA What you missed in this course(lab, exam etc.)Date and time of exam(if applicable)Student’s statement:I certify that I was unable, on the dates stated above, to meet academic deadlines in the course(s) listed above and hereby authorize thisphysician/counsellor to provide the following information to UOIT and, if required, to supply additional information relating to my request forspecial consideration. I acknowledge that submission of false statements or documents is a violation of the university’s academic regulations.Student’s signatureDateSIGN HERENOTE: THIS APPLICATION WILL NOT BE PROCESSED UNLESS IT IS SIGNED AND DATED.

[There are two pages to the Medical Statement form. The student is required to complete Section A. The physician/counsellor is required tocomplete Section B. Both completed pages of this form are to be received by UOIT within five days of the missed deadline or exam date.]Student to complete this section for the physician/counsellor.Student’s last name Student’s first name Student numberSection B: To be completed by the treating physician/counsellorGuidelines for physician/counsellorFaculties may grant deferred examinations or excuse late assignments or student absences in cases of incapacitating illness. This form isintended to provide the dean or dean’s designate with sufficient health information to allow them to make a decision regarding the student’srequest for special consideration due to health problems. The original copy of this form will be placed in the student’s permanent file in theRegistrar’s office.The physician/counsellor is requested to complete the appropriate parts of this form as fully as possible to enable full consideration to be given tothe student’s request. Please return both Section A and Section B of this form in a sealed envelope to the student, scan and e-mail, or fax itdirectly to the appropriate university office (as indicated by the student on the first page of this Medical Statement. Thank you for your assistance.Date of medical examinationDate(s) of illness (or acute episode if problem is chronic)from:to:1. Based on my medical examination I feel that the individual named above is/was unable to complete the required academicresponsibilities because of an incapacitating illness.2. I have examined the above named individual and found signs and symptoms that merit consideration for deferral.3. I did not examine the individual named above while symptoms were present.Physician’s/counsellor’s comments on the duration, severity and nature of the individual’s illness:Address and telephone number(stamp, business card or letterhead acceptable)Printed name of physician/counsellorRegistration No. CPSOPhysician/counsellor signatureDateThe information requested on this form is collected under the authority of the University of Ontario Institute of Technology Act, 2002. Thisinformation is being collected for the purpose of a deferred examination or other special consideration. Inquiries concerning the collection ofthis information should be directed to Mr. Leslie Becskei, associate registrar, UOIT, 905.721.3177.Please note that any costs incurred as aresult of having this form completed, must be paid by the patient.