Please Carefully Review the Philosophies and Statutes of Duquesne University and the John G

DUQUESNE UNIVERSITY John G. Rangos, Sr. School of Health Sciences Medical Release Approval Agreement Form

A student who wishes to return to the Rangos School of Health Sciences after a Medical Leave granted through the Dean’s office must complete this form and submit a copy to his/her Department Chairperson and the Office of the Dean (302 Health Sciences Building) with all appropriate medical documentation. The student must receive clearances from all treating health care providers to resume academic activities.

Student Name:______Student I.D.# ______

Major Area of Study______Year in Program ______

Email Address______Telephone ______

1. List specific condition ______

2. Name of Medication and/or healthcare provider(s). ______

3. How often and when is the medication taken and/or scheduled healthcare provider(s) treatment(s)? ______

4. When did you start taking this medication and/or scheduled healthcare provider(s) treatment(s)? ______

5. Describe any side effects or necessary steps required by your healthcare provider(s). ______

______

Please attach documentation from your treating healthcare provider(s) verifying that you are cleared to return to your program of academic and clinical study full-time. In that documentation, your treating healthcare provider(s) must directly indicate that the medical condition(s) which required you to take a leave of absence do not pose any health or safety risks for you, your peers, and specifically, the clinical clients who will be under your care. Finally, your treating health care provider(s) should detail any limitations or continued treatment that could impact your academic and clinical education and the health or safety of you, your peers, and the clinical clients who will be under your care.

This information is true and correct to the best of my knowledge. I agree, understand and will comply with the prescribed treatments and their restrictions during my tenure in the Rangos School of Health Sciences.

Student Signature ______Date______

Original – Department Copy – Office of the Dean Copy – Student

4/2/14