Medical Statement - University of Ontario Institute of Technology

[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.