PERSONAL DECLARATION CERTIFICATE

This form is to be completed by students who have been absent from classes owing to illness, or other circumstances beyond their control. It should be submitted without delay to the relevant Department office(s) or Flexible Combined Honours office. If the illness/absence continues for more than six consecutive days, or it results in absence from an examination, a doctor’s certificate or other corroborative evidence from an appropriately qualified professional will be required.

Full Name:

Student Number:	

Term time Address:

Programme of Study:							Programme Stage:

1. Date you became unfit/unable to attend:

2. Date you expect to be fit to resume classes:

(if you expect to be unfit/unable to attend for more than 6 days after date given in (1) above, enter  “not known”)
3. Brief details of reason:

I understand that:

a. if my absence continues beyond the date given in (2) above, I must obtain a medical certificate or other corroborative evidence from a qualified professional (eg. A Counsellor)

b. if my absence prevents me from attending an examination, including practical examinations, I must ensure that a medical certificate or other corroborative evidence from a qualified professional (eg. A Counsellor) is sent to the appropriate Department Office, as self-certification of illness will not be taken into account by Examining Boards.

Signature of student:

Date: