Injured Athlete - Application for Temporary Accommodations

Student Information
Name*

Student's First NameStudent's Last Name
Semester*
Sport*
Date of Injury*
Nature of Injury*
Please describe the injury or injuries here.
Date Range for Anticipated Absence*
Please enter the dates that the student will be absent from class.
Return to Class Date*
Please enter the date the student will return to class.
Physician's Note*

Please attach the official physician's note here. This must be on official letterhead and signed by the physician.
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Which accommodations are being requested during the student's absence?

No academic readingNo use of screens (i.e., computers, phones, television, etc.)No academic activity (i.e., writing, working on assignments, quizzes, tests, etc.)Email notes/presentations & handouts used during absence, unless already in BlackboardOther
If you selected "Other," please indicate the accommodations here.
Upon returning to class, which accommodations will the student need?

Preferential seating in class that allows student to leave class with minimal disruptionPermission to record lecturesProvide notes/presentations in class, unless already in BlackboardAlternate class location due to mobilityOther
If you selected "Other," please indicate the accommodations here.
Quizzes and tests missed during related absence can be made up within # class days after returning.
Assignments missed during related absence are due # class day(s) from student's return to class.
Should be Empty:

Reporting Athletic Director or Athletic Trainer Information