CSU Student Medical Certificate PDF

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Division of Student Administration

CSU Student Medical Certificate Instructions This form is to be used when applying for special consideration for examinations or other assessable work studies on medical grounds. Refer to the Special Consideration Policy for further information. YOU ARE REQUIRED TO: (1) complete Section 1; (2) give this form to your Medical Practitioner or Health Care Provider to complete Section 2 and have the provider’s stamp affixed. All sections must be completed; (3) submit a copy of this form as an evidentiary documents with your Request for Special Consideration. If withdrawal from the subject has been approved, you may then submit an Application for Remission / Reimbursement if your circumstances meet the criteria.

1. Your Details Student Name:

Student Number:

By submitting this form, I understand that CSU may contact the medical practitioner to provide further details to CSU in order to discuss and verify the implications of the illness/condition of which I am suffering. I understand that submitting fraudulent medical documentation could result in suspension or exclusion from the university.

NOTE: The section below is a legal medical certificate and may only be filled out or adjusted by the medical practitioner.

2. Medical Practitioner / Health Care Provider (Special Consideration Regulations 5.1.4) Name of Practitioner Provider Number PROVIDER’S STAMP or PRACTITIONER NUMBER must be affixed here

Address Contact Telephone(s) Date of Attendance

D

D

/

M

M

/

Y

Y

Y

Y Time:

I certify that

PATIENT’S NAME

My assessment of the patient is based on examination and is in my opinion (please tick relevant circumstance): Unfit for full time work/studies Or Requires a reduced work/study load The condition is (please tick): Permanent Infectious

Episodic/fluctuating

Deteriorating

This condition would (please tick): Severely affect Moderately affect Slightly affect I am unable to assess how this illness would affect the patient’s capacity.

Improving

Not affect

This condition would affect, in such a way as noted above, the patient’s capacity to: Attend classes Participate in fieldwork Complete assignments Sit examinations Complete workplace learning D

For the Period:

D

/

M

M

/

Y

Y

Y

Y

D

D

/

M

M

/

Y

Y

Y

Y

To:

From:

Within the limits of patient confidentiality, please state the nature of the problem/illness/difficulty experienced by the patient over this period. ……………………………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………………………. I confirm that I am a registered medical/health practitioner. I confirm that I am not a family member and do not have a personal relationship with the student. Practitioner’s signature:

PRACTITIONER’S SIGNATURE

Date:

D

D

/

M

M

/

Y

Y

Y

Y

Privacy & Health: The personal information you provide on this form to Charles Sturt University (CSU) is governed by the Privacy and Personal Information Protection Act 1998 (NSW) and Health Records and Information Privacy Act 2002 (NSW). The personal information you provide will not be made available to any other person or organisation outside of the University or for any other purpose without your consent or where authorised by law, and will be disposed of in accordance with Government regulation. If you are unhappy with the way we have handled or failed to handle your personal information you may apply to have the matter reviewed by lodging a formal application to the University Secretary whose address is given below. The University Secretary, Charles Sturt University, The Grange, Panorama Ave Bathurst, NSW Australia 2795

SA-Enrol-Medical Certificate-0119

Division of Student Administration

CSU Student Medical Certificate Information for Registered Practitioner Statement Charles Sturt University (CSU) appreciates you taking the time to help our student assess the impact of their illness or injury. The information you provide here will ensure that the assessment process is fair and equitable. These guidelines have been written to assist you, as a medical/health practitioner, to understand the purpose and use of the CSU Student Medical Certificate in the special consideration process. The purpose of special consideration is to give a student, whose study progression has been adversely affected by an extraordinary event beyond their control, a further opportunity to demonstrate their ability. 1. What is special consideration granted for? Special consideration may be granted to a student in circumstances of acute illness or condition, or an extraordinary circumstance which has directly impacted their ability to perform an assessment task. Please be aware that CSU has a variety of support services available for students who may be experiencing chronic illness or disability. They include Disability Services (for assessment and examination adjustments) and Support Services (for counselling and psychological services). 2. Use of the CSU Student Medical Certificate This CSU Student Medical Certificate is included in the application that a student submits to CSU for special consideration. It will allow CSU to verify the student’s claim and to determine the form of consideration to be given based on the student’s circumstances. The information you supply on the form will be made available only to those members of staff who need access to it in order to carry out their duties in accordance with CSU’s privacy policy. 3. What information must a CSU Student Medical Certificate include? The CSU Student Medical Certificate must include: a. The practitioner’s name, contact details, provider or registration number and signature b. The date of the consultation c. An evaluation by the practitioner, psychologist, etc. of the duration and degree of impact on the student’s ability to attend classes, study or complete assessment requirements d. The date the statement was written and signed. Please issue the statement in line with guidelines provided by your professional association and only in respect of an illness, injury or extraordinary circumstances that you have observed. Please do not provide post-dated statements, as these will not be accepted by CSU.

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