Academic Relief Request Form

 

Date __________________
 
1. Name  ID#
2. Campus Address

 

 
Permanent Address

 

 
3. Telephone # Work#  E-mail
4. College (Circle Class): FR      SO      JR      SR      GRAD
5. Overall GPA  GPA Previous Semester
6. How many classes have you missed this semester because of difficulties?

 
7. Have you been to the Cook Counseling Center to address this condition? Yes______ No_______
 
Which providers have you seen?

 
Have you been to other outside facilities? Yes ______ No ______

You must submit documentation of those visits. (see documentation guidelines).

 
8. Have you been hospitalized for this condition? (If so, when, where and why?)

 

 
How many days?
9. Is this the first time you have applied for academic relief? Yes ______ No ______
If no, what other semester(s) have you been granted or applied for relief? (Additional requests for academic relief are normally not granted for the same condition.)

 

 
10. Describe the condition and how it has impacted your academic performance.

 

 

 

 

 
11. What strategies did you use to resolve the problem before making this request? (ex. Workshops, study groups, professor’s help, etc.)

 

 

 

 

 
12. What are you doing now to improve your academic success?

 

 

 

 

 
13. What type of academic relief are you requesting? Check all that apply.

___Medical Withdrawals (Medical withdrawals require a hold of re-admission pending evidence of treatment.)

___Incompletes (Recommended incompletes must be approved by instructor and requests for an incomplete must be made prior to the last day of classes for the semester in which the class is being taken.)

___Late Course drops

___Specific Course Drops from previous semester (In most circumstances specific course drops are not granted.)

___Other (specify):
Please specify course and number, CRN number, and semester enrolled for course drops and incompletes: (ex. MATH 1526 13243/FALL 2006)

 

 

 

 

 

 

 

 
I have read and understand the policies and guidelines regarding academic relief. I grant permission to the Academic Relief Committee of Cook Counseling Center to contact me to clarify my request for academic relief and to review my Cook Counseling Center records. I also give permission to contact my outside providers if additional information is needed about my condition. If my request is approved I also grant permission to the Academic Relief Committee to provide a recommendation to my academic dean.
Signature ________________________________________ Date:


Revised 11/15/06