Certificate Of Mailing For The Petition For Appointment Of Guardians - New York University Page 2

ADVERTISEMENT

NYUStudentHealthCenter
Certification of Readiness to Return to School
from Medical Leave of Absence
To the evaluator: The student named below has requested to return from a medical
leave. The information you provide will be used to determine the appropriateness of
the student’s return to school. A signed release is attached to this form. Please
complete this form, answering all questions, and return it with your signature and the
student’s signature providing release of information. Thank you for your assistance.
Today’s Date: ____/____/____
Student’s Name:___________________________________________ Student’s Date of Birth: ____/____/____
1. Date you began working with the student: ____/____/____
2. How often have you seen the student? _______________________________
3. Describe the student’s impairment at the beginning of the medical leave (please specify symptoms
and include diagnosis).
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
4. Explain the current status of the impairment and of the original symptoms.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
5. Explain specific conditions or circumstances which may exacerbate the condition.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
PLEASE COMPLETE REVERSE SIDE
NYUStudentHealthCenter | Counseling and Wellness Services
07/12
726 Broadway, Suite 471 • New York, NY 10003 • 212-998-4780 •

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 3