Fillable Medical Leave Of Absence Form printable pdf download

Accessibility Services

MEDICAL LEAVE OF

accessibiltyservices@royalroads.ca

ABSENCE FORM

Fax: 250-391-2670

2005 Sooke Road Victoria BC V9B 5Y2

STUDENT INFORMATION AND AUTHORIZATION FOR RELEASE OF INFORMATION

The personal information collected on this form is collected under the authority of the University Act and is subject to the Freedom of

Information and Protection of Privacy Act. The personal information collected will be used for assessing medical needs, in relation to

Medical Leave of Absence. For more information regarding the collection and use of personal information please contact Royal Roads

University’s Privacy Officer at 250 391-2600 (ext 4178) or via email at: info@royalroads.ca, or in writing at above address.

STUDENT IDENTICICATION (required)

I hereby authorize my healthcare practitioner to complete this form. I authorize my healthcare provider to fully

respond to the requested statement questions below as they relate to taking a Medical Leave of Absence at Royal

Roads University. ***Any fees incurred for completion of this form are the responsibility of the student

Student name: ___________________________Signature:_________________________Date:_______________

Student Number: _______________ Program: _______________Email:__________________________________

Please note:

Students holding medical leave status are not normally provided with academic supervision or access to the

university’s facilities or services. Exceptions are granted with the express permission of the Dean or designate.

The student may be required to repeat previously taken courses to ensure currency of material.

The student will be responsible for clearing any outstanding balance with the university when granted this leave.

Students who are unable to return within the predetermined timeframe will be required to obtain further medical

documentation to substantiate a further extension or will be withdrawn.

***It is recommended the student contact Financial Aid and Awards to investigate the impact of the MLOA on

Student Loans and/or other financial considerations.

HEALTHCARE PRACTITIONER STATEMENT

Following examination, I certify that the above named person requires a Medical Leave of Absence from their

studies at Royal Roads University due to the following medical condition, illness or disability:

___________________________________________________________________________________________

Start Date:____________________________ ***Please note, all MLOAs are for one year in length, and all

students must be medically cleared to return.

MLOA extensions are also for one year. Is this an extension of an existing MLOA? Yes ☐

☐

HEALTHCARE PRACTITIONER IDENTIFICATON

Name of Attending Health Care Professional: _____________________________________________

Specialty/Occupation of Health Care Professional:__________________________________________

Signature:________________________________________ Date:_____________________________

Address:_________________________________________ Phone:___________________________

Medical Leave Of Absence Form