Explanatory Statement For Student Absence From Class Or Work
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1Explanatory Statement for Student Absence from Class or Work
Students who have missed required term work because of incapacitating distress or illness must refer to the
policies and procedures put in place by the instructor and/or the college. Students may be required to submit this
form in addition to requirements outlined in the course syllabus.
1. Student Name ____________________________________________________________
2. Department, course and section ______________________________________________
3. Date(s) of absence ________________________________________________________
4. Reason for absence _______________________________________________________
5. In case of absence due to illness, please answer the following:
(a) Did you visit a medical facility because of this illness?
No
Yes
Name of facility
_____________________________
Date(s) seen
________________________________
(b) Did you receive professional medical advice by phone, text or email?
No
Yes
From whom?
________________________________
Date(s)
____________________________________
(c) What was the nature of the advice? (For example: Take a prescription; rest; dietary advice)
(d) If your answers to (a) and (b) are No, can you give the name of someone who can vouch for the fact you
were ill?
No
Yes
Name of person
___________________________________
Telephone number
_________________________________
Relationship
RA
Faculty
Family
Friend
Other (specify) _________________________
STUDENT DECLARATION
I understand that under section (4.2 a, item 7) of the student code of conduct that misrepresentation to avoid ac-
ademic work by fabricating an otherwise justifiable excuse such as illness, injury, accident, etc., in order to avoid
or delay timely submission of academic work or to avoid or delay the taking of a test or examination is academic
dishonesty and is punishable (4.2 b) by academic sanction which may include a failing grade.
_______________________________________
______________________________________
Student Signature
Date
Signature of Person verifying illness (5d)
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