MEDICAL LEAVE OF ABSENCE CERTIFICATE by ild18893

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									                            MEDICAL LEAVE OF ABSENCE CERTIFICATE



LEARNER’S AUTHORIZATION FOR RELEASE OF INFORMATION

I, __________________________________________ hereby authorize my physician to complete this
“Physician’s Statement”. I authorize my physician to fully respond to the requested statement questions
below as it relates to my request for a Medical Leave of Absence from my studies at Royal Roads
University.

Learner’s Signature__________________________________ Date__________________________________

Learner ID Number_________________________________ Program_______________________________




                                       PHYSICIAN’S STATEMENT

Confirmation of illness:

1. Following examination, I certify that the above named person requires a Medical Leave of Absence from
    their studies at Royal Roads University due to the following medical condition or illness:
     ________________________________________________________________________________________
     ________________________________________________________________________________________
     ________________________________________________________________________________________

2. This condition or illness currently prevents this person from continuing with their studies because:
     ________________________________________________________________________________________
     ________________________________________________________________________________________
     ________________________________________________________________________________________

3. Has this person been prescribed a course of treatment for the medical condition that has rendered them
    unable to continue in their studies or has such a course of treatment been recommended?
     ________________________________________________________________________________________
     ________________________________________________________________________________________
     ________________________________________________________________________________________




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4. If a course of treatment has been prescribed or recommended, has this person followed the prescribed or
     recommended course of treatment?
     ________________________________________________________________________________________

5. Please indicate dates of Leave Eligibility:

   Start_______________________________________             Estimated End______________________________

6. The date this person was last seen by me regarding this illness/injury was _________________________.

Other comments:
     ________________________________________________________________________________________
     ________________________________________________________________________________________
     ________________________________________________________________________________________




Name of Attending Physician:          __________________________________________


Address: __________________________________________ Phone: ________________________________

           __________________________________________

Signature:_________________________________________ Date: _________________________________




*To return to active status, learners must provide documentation attesting to their fitness to return to
study. The University reserves the right to request documentation as deemed necessary by the Disability
Services Coordinator. The learner must also work with their Program to develop a “Return to Studies
Work Plan” for approval by the Dean. These documents must be submitted a minimum of one month
prior to the anticipated return to studies date given by the attending physician.



The information in this report is considered confidential.
Any charge for completion of this form is the responsibility of the Learner.
This document may be faxed to the University Life office at (250) 391-2500.




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