Health Care Provider Stamp (clinic name, contact info)
CERTIFICATE OF ILLNESS FOR ACADEMIC CONCESSIONS
For Undergraduate Students
SFU Undergraduate students must submit the Certificate of Illness form to instructors when requesting concessions, for class absences, missed assignments, mid-terms and/or final exams (not to be used for the withdrawal of a course).
This note confirms that __________________________________________, _________________________ was seen by Student¡¯s Name Student Number
______________________________________________________ on _________________________________________.
Health Practitioner¡¯s Name Date
TO BE COMPLETED BY HEALTH CARE PROVIDER: Please fill in ONE of the THREE sections below.
1
At the time of this examination the student has been ill since ______________________________________ There is evidence to substantiate this claim and the illness will likely continue for __________ more days.
The illness is expected to be self-limiting and should not impact beyond the dates above.
The condition may impact the remainder of the semester. (Student to discuss arrangements with instructor, if necessary.)
Comment (optional): ________________________________________________________________________________________________
_________________________________________________________
Health Practitioner¡¯s Signature
2
At the time of this examination the student was not ill, however the student states he/she was ill on ____________________
_________________________________________________________
Health Practitioner¡¯s Signature
Date(s)
3
This student is/was unable to attend class on ________________________________ due to a medically related appointment
Date/Time
_________________________________________________________
Health Practitioner¡¯s Signature
PLEASE NOTE THAT, IF THERE IS A CHARGE FOR COMPLETING THIS FORM, THIS IS THE RESPONSIBILITY OF THE STUDENT.
STUDENT STATEMENT
By signing below I, the applicant, consent to the collection and use of personal information about me as noted above. I understand that failure to consent may result in rejection of my application for extension/deferral.
Student Signature
Date
Freedom of Information and Protection of Privacy
The information on this for is collected under the authority of the University Act [RSBC 1996, C.468, s27 (4)(a)], and is related directly to, and needed by the University for, making a decision on your request for extension or deferral. The information will be used only for this purpose. If you have any questions about the collection and use of this information contact your course instructor or departmental advisor. In addition to the personal information collected on this form, the instructor may need to contact your health care professional to discuss your application for extension/deferral. Any additional personal information collected from your health care professional relates specifically to the concessions you require. This information is collected and used for the same purposes as noted above.
Revised May 2018