Medical Supplement

This form assists students in providing documentation of a medical or disability condition when petitioning for an exception to a University policy.

Part B of this form must be completed by a physical or mental health care/medical professional or a Disability Resource Center (DRC) access consultant.

View the Medical Supplement Form

Privacy notice: The information on this form will be used to consider the request you are making. It will be viewable by University staff with a business need in order to take action on your request. You are not legally required to submit this information, however declining to submit the information will prevent the University from accurately reviewing your request and taking action.

Use this form if...

  • You are petitioning an academic policy exception due to a medical condition or disability that affected your ability to meet academic requirements (e.g., requesting a late withdrawal, grade change, or extension).
  • You are requesting a tuition refund appeal due to a medical condition or disability.

Don't use this form if...

  • You are requesting an academic exception or tuition refund appeal for non-medical reasons.
  • You are requesting general disability accommodations. You should work with the Disability Resource Center (DRC) instead of using this form.
  • You are faculty/staff and not a student. This form is only for students at the University of Minnesota. Faculty and staff should follow HR policies for medical leave or workplace accommodation.
  • You are requesting short-term absences for minor illnesses. If you miss a few classes due to a minor illness (e.g., cold, flu), you should contact your instructors directly rather than submitting this form.
  • You are seeking a medical withdrawal for future terms due to a medical condition. See our Withdraw page and/or Leave of Absence (LOA) page for further information.

 

Next steps

This completed form should be attached to and submitted with an appeal or petition. The Medical Supplement serves as documentation for consideration in the appeal or petition process. Attach this with the required appeal or petition form. This form is NOT submitted alone.