Explanatory Statement for Absence from Class or Work

The Student Health Services (Infirmary) can not release protected health information ( Which includes dates and times our services are utilized) due to federal HIPPA regulations relating to health care privacy. However, we do share in the common goal with the University of Arkansas at Pine Bluff to have students attend class in a good state of health. If an illness will prevent a student from attending classes for an extend period of time the Dean of Students will be notified with the students's permission.

First Name

Last Name

Department, course and section

Date(s) of absence

Reason for absence

In case of absence due to illness, answer the following :

Did you visit the Student Health Services?

YesNo

Date seen

Did you call and receive advice from a nurse at the Student Health Service?

YesNo

Date of Call

Were you seen at another facility?

YesNo

Doctor's Name

Date seen

If your answers to (a) or (b) are "No" can you give the name of someone who can vouch for the fact you were ill?

YesNo

Name of person and telephone number

Contact Information