Brunel Medical Centre > Forms > Medical Request Forms > Student Request Form

Student Request Form

Student Services

Student Forms

This page is designed for Brunel University students who wish to submit extenuating circumstances or disability forms. Please choose the correct pathway for your particular needs. Our new and improved process ensures that all requests are processed digitally, in a timely manner and without the need to submit paper documents. A response will be emailed to you within 5 working days. You do not need to print the forms or visit the practice.

Please visit Brunel University support pages by following the link below before submitting your application.

UNIVERSITY SUPPORT

INFORMATION

Important Notes to Remember

Illnesses of less than 7 days does not require certification
Minor ailments are not eligible for certification (e.g. prolonged flu/cold etc.)
Pregnancy and other conditions that are protected by the law do not necessarily require certification
If you do not qualify for extenuating circumstances or disability support then you will be signposted to the “University Support Tab” for further assistance. Please follow the link below.

Please Choose one of the following reasons

Extenuating Circumstance

Disability Form

Extenuating Circumstances

Extenuating circumstances are granted where an individual has an illness, condition or injury that affects their ability to undertake the activities of daily living, such as washing, dressing and eating.

Name

Forname

Surname

Date of Birth

Student Number

Address

Postcode

Town

Country

Please list all your health conditions

Use the fields provided below to list each of your medical condition separately. Please also clearly state how the condition is affecting you in the relevant field. This will help our clinicians to accurately review and complete the form.

Medical Condition 1

Medical Condition 2

Medical Condition 3

Medical Condition 4

How does the condition(s) affect you?

Start date of when affected

End date of when affected

Please state the modules or assessments affected

I would benefit from:

Deadline extension

Adaptations or support required

Other

Please provide further details

Please suggest what support may help you.

Is there any further information you wish to add?

Name of Person Requesting Confirmation

I confirm

I am unable to complete my activities of daily living due to my illness

Signature

Clear

Disability

Disability is defined under the Equality Act 2010 as having a physical or mental impairment that has a substantial and long-term (usually greater than 12 months) adverse effect on your ability to undertake activities of daily living.

Disability Form

Please complete the form below.

Name

Forname

Surname

Date of Birth

Student Number

Address

Postcode

Town

Country

CONDITIONS

A physical condition

A mental health condition

State what this is and how it is affecting you.

Does your condition affect the ability to carry out day to day normal activities, such as washing, dressing, eating or continence ?

State the condition or diagnosis as you understand it and how it is affecting you?

Does your condition impair motivation, concentration, attention or ability to retain information?

Does your condition cause impaired mobility, manual dexterity or ability to lift, carry or move everyday objects?

Does your condition affect your perception of the risk of danger to yourself?

Does your condition cause impaired communication skills?

Could your condition pose a risk to yourself or others?

Does your condition affect your sleep or your energy levels?

Driving

In the interests of road safety, those who are affected by a medical condition likely to cause a sudden disabling event at the wheel or who are unable to safely control their vehicle from any other cause (decreased reaction times) should not drive

Student Consent

I consent to this form being returned to the member of staff set out above. I am aware that if the Medical Centre do not have evidence of a condition requiring my absence from university for more than 7 days or a long term condition that is continuing to be monitored, the form will be returned to the member of staff, confirming this

Name

First

Last

Signature

Clear

If you are human, leave this field blank.

Student Request Form

Student Forms

UNIVERSITY SUPPORT

INFORMATION

Extenuating Circumstances

Please list all your health conditions

Disability

Disability Form

Driving

Student Consent

Brunel Medical Centre

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