MBBS Self-Certified Absence Form 22/23

MBBS Self-Certified Absence Form 22/23

This form should be completed if you have been unable to attend your studies.
For students who have missed teaching or placement days due to illness:

If you have been absent for longer than 5 days, please complete a second form. In case of absence due to illness, after 7 days of continuous absence (including weekends), you will need to provide a doctor's certificate.

For students requesting leave in advance:

Please complete all parts of this form if you wish to request a period leave which requires you to miss learning events. Priority will be given to requests involving portfolio development opportunities such as conferences.
Name*

PrefixFirst NameLast Name
Student ID*
Enter 9 characters
QMUL Email*

Confirmation Emaila.student@smd18.qmul.ac.uk
Phone Number*

Area CodePhone Number
Year of Study*
Group*
Absence or leave request*
Current Module*
eg FunMed, BB2, HSPH, Lecture week, DATE, etc)
Has your tutor for the session or placement been informed?*
How many days absence are you recording?*

12345
First Day of Absence*

DayMonthYear
Activity (Check all that apply)*

ANATOMYCLINICAL & COMMUNICATION SKILLSHOSPITAL PLACEMENTGP PLACEMENTMICROANATOMYPBLPHYSIOLOGYPROGRESS TESTOther
Second Day of Absence*

DayMonthYear
Activity (Check all that apply)*

ANATOMYCLINICAL & COMMUNICATION SKILLSHOSPITAL PLACEMENTGP PLACEMENTMICROANATOMYPBLPHYSIOLOGYPROGRESS TESTOther
Third Day of Absence*

DayMonthYear
Activity (Check all that apply)*

ANATOMYCLINICAL & COMMUNICATION SKILLSHOSPITAL PLACEMENTGP PLACEMENTMICROANATOMYPBLPHYSIOLOGYPROGRESS TESTOther
Fourth Day of Absence*

DayMonthYear
Activity (Check all that apply)*

ANATOMYCLINICAL & COMMUNICATION SKILLSHOSPITAL PLACEMENTGP PLACEMENTMICROANATOMYPBLPHYSIOLOGYPROGRESS TESTOther
Fifth Day of Absence*

DayMonthYear
Activity (Check all that apply)*

ANATOMYCLINICAL & COMMUNICATION SKILLSHOSPITAL PLACEMENTGP PLACEMENTMICROANATOMYPBLPHYSIOLOGYPROGRESS TESTOther
Reason for Absence(s)*

CONNECTIVITY ISSUEHARDWARE ISSUEHEALTH ISSUEPERSONAL CIRCUMSTANCEOther
Please be aware that the Student Academic and Pastoral Support Office at QMUL Barts & the London School of Medicine and Dentistry is available to you, where you can receive support from our staff who are experienced in helping and advising students across a range of issues.

If you have a physical or mental health condition or concern, you are strongly encouraged to contact the Student Academic and Pastoral Support Office who will provide help and guidance to minimise any negative impact on your studies and/or academic progress.

To make an appointment you can email smd-student-support@qmul.ac.uk or call 020 7882 2234
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