Medical Supplement Form

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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 (
otr172.pdf), 13-credit Exemption Request ( otr158.pdf, and/or Tuition Refund Appeal (
umn.edu/forms/otr/otr241.pdf) along with the Medical Supplement. 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 ). Please add the required signature(s) in blue or black ink.
PART A. Student information
Student name (last, first, 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 ____________________________)
confined 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 specific 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: ___________________
Difficulty interacting with others
Other: ___________________
Other comments pertinent to the student’s circumstances:
PART C. Certification
Name/title
Date
Signature
Name of service provider/hospital/clinic
Phone number
To request copies of this form in an alternative format, please call a Disability Resource Center liaison for financial aid at
*0tr174*
612-625-9578. 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.
OTR174 6/15
Please recycle

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