Medical Leave of Absence Health Care Provider Report Form

Student: You are responsible for sharing this link with your health care provider. Be sure that your health care provider has the form in time to complete and submit it so that it arrives no less than 30 days before the beginning of the term in which you are seeking reinstatement. You are responsible for sharing the deadline with your health care provider. The health care provider who completes this form must be your treating licensed mental health care provider, or other licensed health care provider who is familiar with you, the reason(s) for your medical leave of absence, and your treatment during that leave of absence. The provider may not be a relative.

Health Care Provider: Thank you for taking the time to provide important information that will help us determine the student’s eligibility to return to Kalamazoo College. In responding to each question, we want to be clear that the College seeks only medical information that is related to the student’s medical leave of absence and the student’s request to be reinstated. If you wish to add any additional documentation, there is an upload link at the end of the form. The College must receive this form directly from the health care provider. Any form that is received in any other way will be disregarded, possibly affecting the student’s eligibility for reinstatement.

Medical Leave of Absence Health Care Provider Report

Enter the first and last name of the student about whom the health care provider is completing this report
Last, First, Middle Initial
Street, City, State, Zip
Have you treated the student for the condition related to their medical leave of absence?(Required)
Has the student's condition improved since you started treating them?(Required)
In your professional judgement, can the student manage a full course load?(Required)
In your professional judgement, can the student attend a lecture of at least two hours?(Required)
In your professional judgement, can the student concentrate on and grasp complex reading materials?(Required)
In your professional judgement, can the student spend hours studying?(Required)
In your professional opinion, can the student organize and write papers?(Required)
In your professional opinion, can the student balance academic demands with extracurricular activities?(Required)
In your professional opinion, can the student live and learn in a community with others?(Required)
Does the student require additional treatment for their condition?(Required)
Will you continue to treat the student for their condition?(Required)
If the student returns to Kalamazoo College, will they have any restrictions?(Required)
Max. file size: 5 MB.
I certify that all of the information shared on this form is an accurate representation of my professional experience treating the above named student.