Fillable Instructions for Students Part 1 (Wayne State University)

Fill Online, Printable, Fillable, Blank Instructions for Students Part 1 (Wayne State University) Form

Use Fill to complete blank online WAYNE STATE UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Instructions for Students Part 1 (Wayne State University)

On average this form takes 11 minutes to complete

The Instructions for Students Part 1 (Wayne State University) form is 3 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 44 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Wayne State University

BROWSE WAYNE STATE UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Request for Medical Withdrawal
ESP@wayne.edu
Mail/Fax/Email to: Records and Registration Office Drop Off: Student Service Center Lobby
5057 Woodward, Fourth Floor Welcome Center
Detroit, MI 48202 42 W. Warren
Phone: (313) 577-3541, #5 Detroit, MI 48202
Fax: (313) 577-0945
Phone: (313) 577-2100
August 2017 Page 1 of 3
Instructions for Students – Part 1
A Medical Withdrawal is for a student who has a medical condition that makes class participation
impossible. If you are in need of help due to a family membe
r’s medical condition, email
esp@wayne.edu and request an Exception to Enrollment Policy form.
To ensure proper consideration for a medical withdrawal, you must complete a SMART Check and
withdraw from the classes.
A SMART Check will take 20-30 minutes and it is
required. For more information go to:
http://finaid.wayne.edu/receiving/withdrawing.php or contact the Student Service Center.
If this request is for the current semester, prior to the 10
th
week, submit a request to withdraw to your
instructor(s) via Academica by using the Withdraw from a Class feature. Dates for withdrawing can be
found at http://reg.wayne.edu/students/calendar.php
Complete Part 1 of this form. Hav
e your health care provider complete Part 2. Please give
your
provider this instruction page.
In your statement, provide a timeline of what has occurred.
We encourage all students seeking a medical withdrawal to follow the advice of their health care
provider.
Instructions for Health Care Provider – Part 2
The student's request for a medical withdraw hinges on your completion of Part 2.
Please be specific about the diagnosis.
Please do not send case notes.
Please be clear if you recommend, or would have recommended, the student stop attending classes
due to the nature of their diagnosis. Guideline: Would you, if you had a similar condition, be able to
continue school?
Please explain if it is your determination that the condition does not warrant discontinuing attendance.
Please retain a copy of the form for you records.
Our office will be contacting you to confirm the details on the form.
If you have any questions, do not hesitate to contact our office by
email at esp@wayne.edu or call us at 313-577-3541, #5.
By signing Part 1 of this form, our student (your patient) has given authorization for you to share necessary
information with our office regarding their medical condition and whether or not it warrants ceasing attendance.
Request for Medical Withdrawal
ESP@wayne.edu
Mail/Fax/Email to: Records and Registration Office Drop Off: Student Service Center Lobby
5057 Woodward, Fourth Floor Welcome Center
Detroit, MI 48202 42 W. Warren
Phone: (313) 577-3541, #5 Detroit, MI 48202
Fax: (313) 577-0945
Phone: (313) 577-2100
August 2017 Page 2 of 3
A medical withdrawal is a complete withdrawal from all courses. For approved requests, the University Medical Withdrawal Policy will
grant 100% tuition and fee cancellation if a student stops attending ALL classes before the end of the 10th week of the scheduled class
meeting period in a full fall/winter term. Medical documentation will need to confirm that medical attention was provided during this time
period. For medical withdrawals occurring during the 11th or 12th week, tuition cancellation is at the rate of 60% and a WN grade is
entered for each course. There is no tuition cancellation after the twelfth week of the term but a WN grade is entered for each course.
These periods are adjusted proportionally for courses that do not run the full term. While a request is under review tuition payments
should be made as scheduled. WN grades do not affect grade point averages.
Deadline Date for Filing: Fall Term ~ March 1 Winter Term ~ July 1 Spring/Summer Term ~ November 1
If the deadline falls on a weekend, it will be extended to the next business day.
Applications must be received by the filing deadline date because exceptions to the deadline will not be granted.
Part 1. Must be completed by student:
Name (last, first, middle): WSU Access ID:
WSU ID Number.: Phone Number:
ALL DECISIONS ARE COMMUNICATED THROUGH YOUR WSU E-MAIL ADDRESS
Applicable Term/Year (complete one): Fall 20______
Winter 20______ Spring-Summer 20______
Provide all requested data for your classes in the applicable term (per sample line):
Subject & Course
Number CRN
Credit
Hours
Date Last Attended
Date of Drop-
A
dd-
Withdraw Office Use
Sample:
ENG 1000 98765 3 10/31/2012 11/01/2012
Provide a complete timeline of the facts and the resolution you are requesting. If necessary, attach additional pages with
documentation.
Are you a financial aid recipient? (check one) Yes No
If yes and this request is approved, you may have to repay aid for the applicable academic year. For more information, Student
Service Center staff are able to answer your questions at (313) 577-2100 or studentservice@wayne.edu
Certification and Release of Information – I hereby autho
r
ize any physician or hospital to release all information with respect
to myself which may have a bearing on this request. I hereby certify the information provided above is correct and true to
the best of my knowledge.
Student Signature: Date:
Reset form
Request for Medical Withdrawal
ESP@wayne.edu
Mail/Fax/Email to: Records and Registration Office Drop Off: Student Service Center Lobby
5057 Woodward, Fourth Floor Welcome Center
Detroit, MI 48202 42 W. Warren
Phone: (313) 577-3541, #5 Detroit, MI 48202
Fax: (313) 577-0945
Phone: (313) 577-2100
August 2017 Page 3 of 3
Part 2. Must be completed by Health Care Provider
If more than one physician is treating this condition, please provide a separate copy of this sheet to each
Patient’s Name (last, first, middle):
WSU ID no.:
A. Diagnosis (including any complications) Please print:
B. History:
1. Date patient first visited you for this condition (MM/DD/YYYY): __________/__________/__________
2. Did you prescribe that patient should stop attending classes? (circle one) YES NO
a. If yes, date on which you advised patient to stop attending classes: __________/__________/__________
b. If you had seen the patient earlier, would you have advised an earlier stop date? (circle one) YES NO
c. If yes, date you would have advised to stop attending classes: __________/__________/__________
3. Date patient is released to return to classes: __________/__________/__________
4. Upon return to school, will patient have any restrictions? (circle one) YES NO
If yes, describe:
C. Progress:
1. Circle progress made by patient: Recovered Improved Unchanged Worsened
From __________/__________/__________ To __________/__________/__________
2. Did current
condition result in a period of confinement? (circle one) YES NO
If yes, where and when? House: From __________/__________/__________ To __________/__________/__________
Hospital: From __________/__________/__________ To __________/__________/__________
3. Was surgery performed? (choose one) YES NO
If yes, date: __________/__________/__________ Type: Inpatient Outpatient
D. Physical Therapy:
Did the current condition result in a period of physical therapy? (circle one) YES NO
If yes, Date of first visit: _________/_________/_________ Date of most recent visit: _________/_________/_________
Frequency (circle one) Weekly Monthly Other (specify)
If physical therapy is completed, date of final visit: __________/__________/__________
Provider’s Signature: Date:
Provider’s Name (Please print):
Practice Name and Street Address:
City, State, Zip/Postal Code:
Telephone Number: Fax Number:
WSU Access ID:
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Instructions for Students Part 1 (Wayne State University)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 24 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document