PART A. Student information
Student name (last, rst, middle initial) University ID
Signature of student authorizing release of medical information required
Student signature Date
PART B. Medical information
Completed by physician/medical professional or the Disability Resource Center (check one)
Physician/medical professional or the Disability Resource Center met or had contact with the student on (list all dates):
Is this medical condition/disability a continuation of a previous condition?
yes no
If yes, (check all that apply)
Is this a chronic condition?
yes no
Did the student experience a relapse?
yes no
Did the student experience complications?
yes no
Did a change in medication or treatment affect the student’s ability to attend class?
yes no
The duration of the condition or treatment that impacts/impacted the student’s ability to participate in class because of the following:
hospitalization (including day hospitalization) required (from ____________________________ to ____________________________)
conned to bed (from ____________________________ to ____________________________)
The duration/symptoms of the condition or treatment that impacts/impacted the student’s daily functions:
Beginning date of condition and/or treatment: ______________________________________________________________________________
Ending or anticipated ending of condition and/or treatment: ___________________________________________________________________
When do you believe the student can/could resume daily activities, including attending class(es)?
List specic symptom(s) and how they prevented the student from attending and participating in class(es)?
Did the student’s condition and/or treatment affect the following daily functions:
Condition and/or treatment Yes No Condition and/or treatment Yes No
Ability to concentrate
Ability to study
Ability to sleep Low energy level
Ability to attend class Other: ___________________
Difculty interacting with others Other: ___________________
Other comments pertinent to the student’s circumstances:
PART C. Certication
Name/title Date
Signature Name of service provider/hospital/clinic Phone number
MEDICAL SUPPLEMENT
DIRECTIONS—This form assists students in providing documentation of a medical or disability condition when petitioning for an
exception to a University of Minnesota policy. You must complete the Academic Policy Petition (z.umn.edu/AcademicPolicyPetition),
13-credit Exemption Request (z.umn.edu/CreditExemptionRequest), and/or Tuition Refund Appeal (z.umn.edu/TuitionRefundAppeal)
along with this Medical Supplement form. This form must be completed by the medical provider or by the Disability Resource Center
if the student is currently registered with and has provided medical documentation surrounding their condition to the Disability
Resource Center. If additional space is needed, please attach a separate letter on letterhead. The intent of this form is to specify dates
and impact of medical or disability condition.
The University reserves the right to verify the authenticity of any information provided on this form.
To ensure privacy online, open in Adobe Reader (free at Adobe.com). Please add the required signature(s) in blue or black ink.
For assistance with this form, call the Disability Resource Center at 612-626-1333. The University of Minnesota is an equal opportunity employer and educator.
This form is printed on paper made from no less than 20 percent post-consumer waste.
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Please recycle
