ical Leave of Absence Procedure
Online Procedure
Students requesting a Medical Leave of Absence are required to do so within six
months following the end of the semester in which the disability occurred. (Leave
requests for Spring Session I must be submitted before December 4, 2020.)
To be eligible for a Medical Leave of Absence, the student is required to submit a
letter from a treating physician. The letter must be written on the physician's or
hospital stationary and must contain the following information:
Doctor's diagnosis and treatment (what is the medical condition preventing
the student from continuing classes).
Date when treatment began.
Expected date of return to classes.
The physician's letter should be submitted as soon as possible.
A Medical Leave of Absence means that the student will receive grades of "W" for
ALL COURSES taken during the period covered by the requested leave.
Direct your questions to Luz Ruyol, Assistant Director, at
The Health Services Center
Medical Leave of Absence
Procedure: Complete the information requested below.
The information provided on this form will support the application for a Medical
Leave of Absence.
Information provided will become part of the student's medical record and is protected
by FERPA and will not be released without expressed written consent.
This form must be completed by a Physician Only (Medical Doctor, Physician
Psychologist, etc.). Physician prescription pad with all the information requested below
is also acceptable.
Licensed Clinical Social Workers may NOT fill out this form.
Today’s date (MM/DD/YYYY): EMPLID:
Patient’s name:
Diagnosis (dx):
Treatment (tx):
Date when treatment began (MM/DD/YYYY):
Expected date of return (MM/DD/YYYY):
Return Form to:
Luz Ruyol
Physician's Stamp
With license number or
Facility stamp