Fillable Request for Medical Withdrawal (Durham Technical Community College)

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Request for Medical Withdrawal (Durham Technical Community College)

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Request for Medical Withdrawal
Students requesting to withdraw from all courses for medical reasons past the normal deadlines should
complete this form, attach appropriate documentation, and submit the form and documentation to Durham
Tech’s Counseling, Accessibility, and Resources office. Withdrawals past the normal deadline will be
recommended only if the student provides clear, specific medical documentation using the checklist below. The
office is located on Durham Tech’s Main Campus, Wynn Center, room 10-209.
Submit form to counseling@durhamtech.edu
Student Information
Name
Telephone
ID Number
Email
Course Information
Term:
☐
Fall
☐
Spring
☐
Summer
Year
Course Prefix
Course No.
Section No.
Instructor Name
Student Checklist:
☐ I have provided medical documentation signed by a physician.
☐ The medical documentation I have provided includes a specific recommendation from the physician to
withdraw due to medical (health) reasons.
☐ The medical documentation I have provided verifies that the dates of the medical condition correspond to the
term in which I am requesting a medical withdrawal.
☐ The medical documentation I have provided indicates a request for withdrawal from all courses. If not, it
indicates a specific rationale as to why my condition does not require a complete withdrawal.
☐ I am requesting an exception due to extenuating medical circumstances within my immediate family.
Student Signature:
Student Signature ______________________________________ Date______________________
Dean, Student, Development, and Support Recommendation:
☐ The documentation submitted meets the guidelines to receive a medical withdrawal.
Dean Signature ______________________________________ Date ______________________
Administrative Approval:
☐ Assign a grade of “W” for the course(s) listed above.
☐ Change the grade(s) for the course(s) listed above to “W.”
☐ Not Approved. Referred to vice president for final decision.
Instructional Dean Signature ____________________________________ Date_______________
Page 1 of 2, Revised 7/6/2020
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Medical Withdrawal Procedure
1. The student requesting a withdrawal for medical reasons may locate this information on the college
website or should be referred to the Counseling, Accessibility, and Resources office, Wynn Center,
room 10-209 or counseling@durhamtech.edu for further information and appropriate forms. Should the
student need guidance with the process, an appointment with a counselor will be offered. For more
information, contact the Counseling, Accessibility, and Resources office at 919-536-7207, ext.1413.
2. The student should complete the Request for Medical Withdrawal form and present supporting
documentation to the Dean of Student Development and Support for review at
counseling@durhamtech.edu. Acceptable documentation must include a physician’s signature, a
specific recommendation to withdraw due to medical reasons, and dates verifying that the medical
condition corresponds to the semester in which the medical withdrawal is requested.
3. Medical withdrawals will be recommended for all courses within the specified term unless the
documentation clearly states why the student’s medical condition does not require withdrawal from all
courses. Supporting medical documentation will be kept confidential in the office of the Dean of Student
Development and Support.
4. If the Dean of Student Development and Support determines that the documentation meets
requirements, a copy of the Request for Medical Withdrawal form (not the supporting medical
documentation) will be forwarded to each instructor’s appropriate dean for approval.
5. The instructional dean will have the authority to approve or not approve the medical withdrawal.
6. If approved, the signed Medical Withdrawal form will be forwarded to the Admissions, Registration, and
Records office to officially document the withdrawal or change of grade.
7. If the medical withdrawal is not approved, the Dean of Student Development and Support will forward
the concern regarding approval and the Medical Withdrawal form to the Vice President, Student
Engagement, Development, and Support for review and resolution. Should a concern exist regarding
approval, the Vice President will have the authority to review all supporting documentation, including the
medical documentation submitted by the student, to resolve the matter.
NOTE: Students requesting an exception due to extenuating medical circumstances will be considered on a
case-by-case basis.
Page 2 of 2, Revised 7/6/2020
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Request for Medical Withdrawal (Durham Technical Community College)

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Completed 1 October 2020

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