Tufts University

Dean of Student Affairs Office

Return from Medical Leave Worksheet

Policy:

Deadlines: Please follow the deadlines provided on the Medical Leave website.

Semester of desired return / Last day to notify DOSA of intention to return / Last day for receipt of all documentation / Last day to call CMHS/HS for appointment / Last day to have all appointments completed

Contacts: For your convenience, we have created a list of additional resources and contacts that will be helpful throughout the medical leave process.

Material Submission:Please make sure you comply with the deadlines above. Applications cannot be reviewed until all required documentation is received.

Document / Comments or guidelines / Submit to:
☐ / Notification of Intent to Return / Submit a 1-2 line email stating the semester you intent to return from medical leave / Student Affairs Coordinator
☐ / Personal Statement / Download the Personal Statement Form from our website for more information. / Student Affairs Coordinator
☐ / Release of Information / Request and sign a release of information form from each treatment provider and/or system of care you saw while on medical leave.
This form will authorize your provider to share the following information with the appropriate clinician at Tufts University Health Service (HS) or Counseling and Mental Health Services (CMHS).
The purpose of gathering this information is to assist the Committee in determining whether the student is prepared to return to the rigors of postsecondary education, the student’s program of study,the residential community and what supports the student may require to achieve their goals at Tufts.
Information to be released may include:
  • A clinical summary of the course of treatment while away from Tufts University
  • If residential care or another system of care was involved (e.g. partial or day program), an original discharge summary from each system of care must also be submitted.
/ To your treatment provider(s)
☐ / Clinical Documentation / Request your primary treatment provider to complete this form summarizing your treatment course during the leave, the current treatment plan, an assessment of your progress while away from Tufts, and any recommendation for support structures that could be useful upon return. All information must be typed and then faxed. / Please fax to appropriate department specified on the back of the form.
☐ / Unofficial transcripts or faculty-issued progress report / If applicable, submit any unofficial transcripts or faculty-issued progress reports from all classes taken during the leave. / Student Affairs Coordinator
☐ / Official Transfer of Credits / If applicable, for official transfer for credits please follow the process as outlined by the Registrar. / Registrar
☐ / Letters of Reference / If applicable, submit letters from any employment, volunteer work and/or internship in which you participated during the leave. / Student Affairs Coordinator

Non-clinical documentssubmitted to Student Affairs Coordinatorshould be sentviaemailor fax to 617-627-3059.

Meetings:

Resource / Name / Meeting Date
DoSA Resource
CMHS clinician
Health Service Clinical Director or Clinical Designee
Undergraduate advising dean or graduate faculty advisor

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