The Office of the Dean of Students - Student Emergency Absence Notification Form

Contact Information

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Select the reason for request:(Required):

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Today's Date(Required):

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Student Information

Please complete all fields. Requests cannot be processed if all fields are not complete.

Full Name

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UIN

DOB (YYYY-MM-DD)

Description/Narrative

Provide SPECIFIC information to support your request. If information is lacking, your request may be returned to you for further clarification, or not processed due to lack of specific information.

Please provide a detailed description of your absence verification request, including information regarding the specific circumstances that occurred that led to your request. Please note that the final approval of all absences, missed work, and/or extended academic deadlines is determined by the professor.(Required) This field is required.

Date(s) you are requesting absence verification(Required) This field is required.

I understand that if my absence does not fall under the criteria in which Student Assistance verifies, Student Assistance will not process my request. It is my responsibility to work directly with my faculty member(s) on absences that do not meet established Student Assistance criteria. If you are unsure if your absence meets Student Assistance criteria, please review the website for more detail: Student Absence Verification(Required)

I understand

You must make at least one selection.

I understand that it is my responsibility to submit documentation to the Office of the Dean of Students – Student Assistance that covers the dates I am asking for absence verification and I understand that Student Assistance cannot verify dates not included on my documentation.(Required)

I understand

You must make at least one selection.

I understand that while the Office of the Dean of Students – Student Assistance can help verify the documented circumstance, such verification does not guarantee an excused absence, rescheduled coursework, and/or make up exam. The final decision for approval of all absences, missed work, and/or extended academic deadlines is determined by the instructor.(Required)

I understand

You must make at least one selection.

In each case, Student Assistance must have documentation in order to verify the circumstance, take action, and advocate on behalf of a student. Our office may take steps to call medical providers or others to validate any documentation submitted. Submission of falsified documentation by a student may result in charges under the Student Code of Conduct and inability to utilize absence verification in the future.(Required)

I understand

You must make at least one selection.

Supporting Documentation

Your Absence Verification request WILL NOT be processed without original documentation provided to the Office of the Dean of Students – Student Assistance. You can attach supporting documentation directly to your request form by uploading them below. PDF format is preferred.

You may also hand deliver original copies to the Office of the Dean of Students for formal verification:
1200 W Harrison Street, Student Services Building Suite 3030 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

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