STUDENT READINESS TO RETURN FROM MEDICAL LEAVE

Dear Health Care Provider:

Amherst College requires documentation before a student is permitted to return to campus following a medical leave of absence. This documentation is intended to verify a student’s readiness to return to community living and a rigorous academic program, as well as to facilitate conversations with campus resources in order to best support the student’s ongoing care and well-being.

This form should be completed by the student’s medical or behavioral health care provider. The following questions serve to assess a student’s readiness to return to campus.

Answering “no” to any of the questions contained within this document will not necessarily prevent a student from returning to campus. Decisions about a student’s readiness to return will be considered individually by the Office of Student Affairs’ Readmission committee, based on all documentation provided, provider recommendations, and College policies. Feel free to provide additional commentary as an attachment if needed.

Your provider can send this document to the Case Management Department at the Office of Student Affairs via fax (413-542-8488), email (osa-studentenrollment@amherst.edu), or via snail mail at the following address:

Case Management Department
Amherst College Office of Student Affairs
Amherst College
100 Boltwood Avenue
Amherst, MA 01002

COLLEGE RESOURCES

Most students returning to campus access resources for ongoing health care and support. Amherst College offers brief psychotherapy and medication management through the Counseling Center. For students who require long-term, specialized, or intensive outpatient treatment, the Counseling Center provides referrals to local providers.

Primary care services are offered by the Keefe Health Center. Students with a medical impairment that substantially limits one or more major life functions may qualify for accommodations under the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990. Questions regarding medical accommodation should be directed to Ms. Jodi Foley ( jfoley@amherst.edu), Accessibility Services Coordinator.

If you have questions about campus resources, please contact the Office of Student Affairs at 413-542-2337.

Thank you


 

Student Name: ______________________ Class Year: __________ Date: _________________

ACADEMIC READINESS

Students at Amherst College undertake a rigorous curriculum and are responsible for maintaining good academic standing. While students are assigned an Academic Advisor and Class Dean, students are expected to take ownership of their academic progress and seek assistance, as needed.

 YES   NO            Is the student ready to re-engage in coursework (i.e., attend class, meet deadlines, complete work in a timely fashion, seek assistance as needed)?

YES   NO            Is the student able to manage a full course load (4 courses) upon return?

YES   NO            Is the student able to participate in course discussions and engage with peers in appropriate ways?

 

Additional comments concerning your evaluation of the student’s readiness to return to a rigorous academic program:

_______________________________________________________________________________________

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COMMUNITY LIVING

YES   NO            Is the student at significant risk of engaging in behavior that could result in physical harm to self or others?

YES   NO            Is the student able to live independently without close supervision or support while managing his/her/their own self-care (i.e., personal hygiene, safety, eating, sleeping)?

YES   NO            Is the student able to behave in a way that does not substantially interfere with the rightful daily activities of community members in the residential environment?

YES   NO            Is the student able to live and function in a community that can be disruptive to routines (i.e., sleep, study) due to distractions and other causes?

YES   NO            Is the student able to live in an environment where he/she/they might be exposed to substances such as alcohol and other drugs?

YES   NO            Is the student ready to return to a campus residence room with a roommate?

Additional comments concerning your evaluation of the student’s readiness to return to community living:

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  RECOMMENDATIONS FOR ONGOING CARE

Of the on campus resources listed in this document, what supports are recommended for the student when he/she/they return to Amherst College (e.g., weekly meetings with a therapist, ongoing medical treatment, mobility assistance, medication management, etc.)? Please provide as much detail as needed and attach any additional, relevant information to this form.

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HEALTH CARE PROVIDER INFORMATION

Name: _________________________________________________

Specialty: ______________________________________________

Address: ______________________________________________________________________

Phone: ______________________________________ Email: ____________________________

Signature: _____________________________________  Date: ___________________________