FE Student Sickness Notification Form

Student Self Certification

Please complete this form if you are a Buxton College student and are absent due to illness or for other reasons. You need to complete all relevant fields to comply with the University's Student Sickness Policy.

Surname/Family Name

Forename

Student number

Date of birth

dd-mm-yyyy*

Unimail email address

What subject area do you currently study in

Name of the course you are currently studying

Stage/Year of study

How long do you anticipate being away from your studies

1 day*

2 days - 1 week

Over 1 week

* Please give the name of your Group Co-ordinator/Tutor

Please give the name of anyone else who you would like to be informed of your absence

First date of absence

dd-mm-yyyy*

Reason for absence

Please note that if your illness is contagious, eg Swine flu, Mumps, Chicken Pox, etc we will pass this information on to the University of Derby Student Health Service.

FOR OFFICE USE ONLY

Date student returned

dd-mm-yyyy

Have you completed all the relevant boxes?

Use of personal data

Our policy is to only use the data you supply to us for use in regard to the work of the University of Derby. We do not pass on your data to any other third party under any circumstances.