Faculty of Science
Department of Physics
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 extension 3011.
________________________________ __________________________ _______________________ 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:
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