Fillable Medical Impact Statement (La Trobe University)

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Medical Impact Statement (La Trobe University)

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Country of origin: AUSTRALIA
File type: PDF

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Medical Impact Statement
Important information
Special consideration is specifically intended to support
students who have recently experienced unexpected acute
illness or injury that is short-term in nature. Requests for
special consideration on medical grounds must be supported
by a Medical Impact Statement (MIS). This is to ensure that
our special consideration assessment process is fair and
equitable. Please issue the statement only in respect of an
illness, injury or other medical circumstances being presented.
The information you provide will help us determine the
appropriate form of consideration such as an extension,
alternative task or a deferred exam.
Who can complete this form?
The MIS is to be completed and signed by a treating
medical/health practitioner who is not a family member or a
close association of the student. The practitioner must be:
• Australian Health Practitioner Regulation Agency
(AHPRA) registered General Practitioners (GPs),
Psychologist, Psychiatrists
• Registered Counsellor (being a member of one of the
APS, the AASW, or the ACA)
• Other AHPRA registered practitioners which diagnose
and treat medical conditions.
The University does not need to know details of the condition,
we only require relevant information regarding the severity of
the impact or the degree of impairment to make an informed
decision.
Assessing the degree of impairment:
The degree of impairment/impact should be based on the
condition/circumstances that you have observed. Please
follow the below guidelines:
• Hospitalised or incapacitated: for the purpose of
special consideration, is defined as unable to function
as a result of recovering from a surgery or serious
medical condition at a hospital, psychosis episodes
and other life-threatening medical conditions. The
student is not permitted to attend an examination,
study or undertake any assessments.
• Severe: the impact of the condition is very serious and
is likely to last more than two weeks. The student is
significantly affected and should not attend an
examination during the period specified on the MIS.
The student cannot complete university assessments
or the level of performance will be substantially
affected.
• Moderate: the impact of the condition is not severe
and is likely to last for one to two weeks. The student
may be able to attend an examination and undertake
university assessments and the level of performance
is moderately affected.
• Minor: the condition has not had a significant impact
(e.g. mild illness during or close to assessment
submission date). The student is able attend an
examination and continue with their studies and
assessments. Their level of performance is slightly
affected.
Incomplete form will not be accepted, please ensure that the
following information is included:
• the practitioner’s name, contact details, provider or
registration number and signature
• the date of the consultation
• an assessment by the practitioner of the duration and
degree of impact on the student’s ability to attend
classes, study/sit exams, or complete assessment
tasks.
• the date the form was written and signed.
La Trobe University appreciates you taking the time to help our
student assess the impact of their medical condition.
Useful information for students
If your medical circumstances are affecting upcoming or
overdue assessment tasks, please ask your treating
practitioner to complete this form. You must apply for Special
Consideration online and upload the signed MIS within three
business days (inclusive) of the assessment task date.
Applying for special consideration does not guarantee that
special consideration will be granted. While your application is
under assessment, you must continue your assessment task
to the best of your ability and submit it as soon as you are able.
For long-term or ongoing medical circumstances, please
contact Equity and Diversity
(latrobe.edu.au/students/support/wellbeing) for specialised
assistance.
In addition to the special consideration, the University offers a
range of support services including counselling, IT, financial
and Learning support and programs. Please visit Student
Support (latrobe.edu.au/students/support).
Submitting falsified document is considered fraud and the
University treats this matter seriously. This could result in
suspension, exclusion from the University and/or legal
penalties. As a student, you must be aware of your obligations
and responsibilities under the General Misconduct Statute.
Privacy Policy: Refer to the University Policy website at www.latrobe.edu.au/privacy or telephone 1300 LA TROBE (1300 52 87623)
Student Administration | September 2020
CRICOS Provider Number: 00115M
Medical Impact Statement
Health/medical practitioner assessment
Health/medical practitioner to complete
Name of patient:
Consultation date:
(DD/MM/YYYY)
I have determined that in regard to the patient’s capacity to take university assessments, the patient has been assessed as follow:
Able to perform reading or writing tasks
e.g. reports, essays, quizzes, tests etc.
● Yes, as usual*
● Yes, with a degree of impact
● No
Able to perform verbal or physical tasks
e.g. presentations, skill/lab tests etc.
● Yes, as usual*
● Yes, with a degree of impact ● No
Able to perform tasks requiring intense focus for 1-2 hours
e.g. taking an exam
● Yes, as usual*
● Yes, with a degree of impact ● No
The level of impact has been assessed as (*not required if the patient is able to perform tasks as usual):
●
Minor
●
Moderate
●
Severe
●
patient is hospitalised or totally incapacitated
Estimated duration of impact:
Please issue the statement in line with guidelines provided by your
From (DD/MM/YYYY)
Until (DD/MM/YYYY)
Additional comments:
By signing this form, I declare that the student presented to me with a condition and the
information is based on my professional examination and opinion. I am registered with AHPRA
and qualified to verify the student’s health condition. I am not a family member or a close
association of the student.
stamp
Practitioner name:
Registration/provider
number:
Address of practice:
Practice telephone number: Email:
Practitioner signature: Date:
Student Declaration (student to complete)
By signing this form, I declare that all the information provided by myself and the health professional is complete, true and correct and
acknowledge that the University may terminate my studies if I have misrepresented my circumstances. All documents submitted become the
property of La Trobe University. I give permission for La Trobe University to contact my health professional to verify the information on this form
if needed, and for relevant information to be provided by my health professional to La Trobe University.
Student Signature: Date:
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Medical Impact Statement (La Trobe University)

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Completed 14 March 2021

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