MEDICAL CERTIFICATE
Version 11 | Updated 20/07/20 | university of the sunshine coast | cricos provider number: 01595d
www.usc.edu.au | Page 1 of 2
TO SUPPORT AN APPLICATION FOR:
DEFERRED EXAMINATION BASED ON MEDICAL GROUNDS
To enable assessment of an application for a deferred examination based on medical grounds, it is a requirement under the University of the
Sunshine Coast’s (USC) Deferred Examinations - Procedures that USC holds written confirmation from a Medical Practitioner that:
the student was experiencing illness, a serious health problem or serious personal trauma on the day of their examination;
the circumstances were beyond the student’s control;
the circumstances did not make their full impact until the date of the exam; and
due to the circumstances, the student was physically unable to attend the scheduled examination.
This form MUST be completed by a registered Medical Practitioner before or on the day of the examination and is to be attached to an Application
for Deferred Examination form which must be lodged prior to the examination or within three (3) working days after the examination date.
EXEMPTION FROM PENALTIES FOR LATE SUBMISSION OF ASSESSMENT TASK BASED ON MEDICAL
GROUNDS
To enable assessment of an application for a request for an exemption from penalties for late submission of an assessment task based on medical
grounds, it is a requirement under USC’s Assessment Courses and Coursework Programs Procedures that USC holds written confirmation from a
Medical Practitioner that the student was experiencing illness, a serious health problem or serious personal trauma. This form MUST be
completed by a registered Medical Practitioner before or on the day of the due date of the assessment task and is to be submitted in accordance
with the process identified by the relevant School.
REDUCED STUDY LOAD (DUE TO UNDER-ENROLMENT) BASED ON MEDICAL GROUNDS
This form is to be used by international student visa holders for the purpose of providing medical evidence to support their under-enrolment in
any study period where that current enrolment load may affect their ability to follow the recommended study sequence and complete all
required subjects within their Confirmation of Enrolment (CoE) end date. This form MUST be completed by a registered Medical Practitioner at
the time of the illness/condition and retained by the student for future supporting documentation.
REMOVAL OF FINANCIAL LIABILITY AND/OR ACADEMIC PENALTY IN SPECIAL CIRCUMSTANCES
This form is to be used by students who are applying for Removal of Financial liability and/or academic penalty in special circumstances based on
medical grounds. This form must be completed by a registered Medical Practitioner.
REVIEW OF FINAL GRADE
This form is to be used by students who are applying for a Review of Final grade based on special consideration where medical supporting
documentation is required as per the Review of Assessment and Final Grade - Procedures. This form must be completed by a registered Medical
Practitioner.
SUSPENSION OF STUDIES
This form is to be used by international student visa holders applying for a Suspension of Studies for the purpose of providing medical evidence to
support their application and MUST be completed by a registered Medical Practitioner.
1.0 IMPORTANT INFORMATION
This form is to be used by students for the purpose of providing medical evidence to support their application.
• Students applying for special consideration based on medical grounds MUST have a registered medical practitioner complete this form.
• Independent medical certificates will not be considered, unless the certificate contains information as requested under MEDICAL EVIDENCE.
. Certificates merely reporting the student’s account of the illness will not be accepted.
. Non-specific statements that the student was experiencing a “medical condition” or was “unfit for work” will not be accepted.
2.0 MEDICAL EVIDENCE
Medical Practitioner confirmation MUST include:
• when the patient was examined; and
• when the illness commenced; and
• when the illness ended (if applicable); and
the severity of the illness expressed as a medical opinion.
MEDICAL CERTIFICATE
Version 11 | Updated 20/07/20 | university of the sunshine coast | cricos provider number: 01595d
www.usc.edu.au | Page 2 of 2
3.0 STUDENT AUTHORITY FOR RELEASE OF INFORMATION
Student ID Number:
First name:
Last name:
I hereby authorise the Medical Practitioner to release the information given in this document:
Signature: ____________________________________ Date: _____/_____/_____
4.0 MEDICAL CERTIFICATE ALL FIELDS MUST BE COMPLETED
I __________________________________________________, a legally qualified Medical Practitioner, certify that on_____/_____/_____
(Name) (Date)
I examined _________________________________________________________
(Student’s name in BLOCK LETTERS)
Duration of illness, serious health problem or serious personal trauma: ______/______/______ to ______/______/______
Duration that illness, serious health problem or serious personal trauma prevented student attending examination/undertaking the assessment
Task/continuing their studies: ______/______/______ to ______/______/______
The student is experiencing (Diagnosis to be provided with patient consent where possible) ____________________________________________
______________________________________________________________________________________________________________
(If applicable) The implications of the illness, serious health problem or serious personal trauma on the student’s university studies are as
follows:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
NOTE: Where the nature of the illness, serious health problem or serious personal trauma cannot be divulged for privacy reasons, USC will accept
a statement from the Medical Practitioner indicating that the illness, serious health problem or serious personal trauma cannot be revealed.
Tick applicable box(es) below:
In my opinion, I believe that due to their illness, serious health problem or serious personal trauma the student was/will be medically
unfit to sit their examination/undertake their assessment task/continue their studies for the dates stated above.
I believe the following information is also pertinent for assessment of the student’s application for a deferred examination/exemption
from penalties for late submission of an assessment task/reduced study load (please attach additional documents if preferred).
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Medical Practitioner’s signature:
Medical Practitioner’s name and address (OFFICIAL STAMP)
Date: _____/_____/_____
Are you the student’s regular
Medical Practitioner? Yes No
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