Administrative Medical Withdrawal Request Form Withdrawal Term (Page 4 of 4) in pdf

Administrative Medical Withdrawal Request Form Withdrawal Term Page 4

Date: ______________

Name

Administrative Medical Withdrawal Request Form

Student: Medical documentation should be prepared on letterhead, typed, dated and bear the signature of

the evaluator. Please make sure the documentation includes the name, title, contact information, and

professional credentials of the evaluator, and information below regarding the reasons for the petition.

To Medical Professional/Provider:

In order to consider a student for a Medical Withdrawal, a signed letter on your letterhead is needed.

Please address the following information in your letter:

1. Patient’s full name and identification (DOB)

2. Diagnosis – severity of patient’s symptoms

3. Presenting symptoms and severity/impact on his/her functioning (including his/her ability to function

academically during the documented time) and the medical reason why the student could not finish

the semester. This is one of the most important pieces of information and will assist us in making

decisions to grant a medical withdrawal.

4. Any concerns/history regarding the patient’s safety/well-being and whether he/she is a danger to

him/herself or others.

5. Treatment plan

6. Dates of onset of symptoms

7. Dates of treatment

8. Prognosis, i.e. a recommendation, if appropriate, that the patient receive a medical

withdrawal for a particular semester and/or the patient not return to school for a period of time.

9. Your recommendation for a medical withdrawal and for which semester (Fall, Spring

or Summer) due to the patient’s inability to function academically.

You may fax the letter to me directly at (904) 620-2901. Please feel free to give me a call at (904) 620-2175 if

you have any questions. Thank you for your assistance.

Candace Ford

Program Assistant

University of North Florida

Building 39a, Rm. 2100

1 UNF Drive

Jacksonville, FL 32224-2645

Revised 02/17/2015

Page 4 of 4

Administrative Medical Withdrawal Request Form Withdrawal Term Page 4