Administrative Medical Withdrawal Request Form Withdrawal Term Page 2
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Name
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Administrative Medical Withdrawal Request Form
Please type your answers to the following questions in order for SHS/Counseling Center to review the impact
of your medical situation on your academic performance in the semester/course(s) that you are petitioning.
The content of your answers should place heavy emphasis on identifying:
** A diagnosis and symptoms
** The date of onset of the disorder/situation
** Treatment types and dates received
** Any hospitalization
** The number of days/weeks of class missed
** How your ability was impacted in trying to complete course work requirements
1) What did you experience that impacted you during the semester in questions? Please provide a medical
diagnosis and symptoms if applicable.
2) When did the presenting issues begin and how did they impact your academic performance?
3) What type of assistance or intervention did you receive? Please include dates of attendance
4) If you are petitioning for a partial withdrawal, the reason why for a partial withdrawal and explanation as to how
you completed your other courses. Please comment on how the medical issue did not impact your other courses
that semester.
5) Explanation why you did not withdraw prior to withdrawal deadline during the semester once situation was
recognized.
6) If you are petitioning to withdraw from a previous semester, what prevented you from withdrawing before the
end of the semester?
7) Additional Comments:
Please be advised that once the COMPLETED PACKET has been received, the Medical Withdrawal process could take
up to 3 plus weeks. The procedure is as follows:
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A Medical Withdrawal request is reviewed by a member of the Medical withdrawal committee for
completeness.
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Director of Student Health will review the medical component and address any questions with the student or
medical provider.
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It is then sent to the Office of the Vice President of Student and International Affairs for his review. If
approved
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It is sent to the Vice President of Undergraduate Studies for review. If approved
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Records and Registration will be notified. They will make changes on the student’s official record and notify
the cashier’s office to initiate a refund (if warranted).
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If denied, the medical withdrawal will be returned to Student Health Services and you will be notified.
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After the packet has been signed by all departments, Medical Withdrawal determination letters will be
disbursed via email by staff in Student Health Services.
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This process could take two to three weeks.
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