Winter ESP Medical Self-Declaration

Winter ESP Medical Self-Declaration Form

This form is for students in the Enriched Support Program only. Non-ESP students, please contact the Registrar’s Office for medical self-declaration forms.

ESP students: Please only use this form for absences from Winter ESP workshops and CIED and FYSM classes .

For absences from your lecture courses, please contact your professor.

You cannot use this form for any missed exams. Please refer to the Registrar’s Office for exam deferrals.

This form is for short-term illness (if you have a chronic health condition, you must arrange accommodation through the Paul Menton Centre), or for varsity athletes to report game day absences.

This form will be submitted to the ESP Main Office. Please follow up with them for more information if desired (esp@carleton.ca).

Personal Data

Carleton Student Number(Required)

Name(Required)

First Last

Student Carleton Email Address (@cmail)(Required)

Please follow the format firstnamelastname@cmail.carleton.ca with no dots between your first and last name.

Course(s) Affected by Medical Issue(Required)

Select all that apply

FYSM 1900 A (Devron Colley)

FYSM 1900 B (Al Blunt, Tuesday)

FYSM 1900 C (Beth Hughes, 10 am)

FYSM 1900 D (Al Blunt, Thursday)

FYSM 1900 F (Susan Burhoe, Wednesday)

FYSM 1900 G (Susan Burhoe, Tuesday)

FYSM 1900 H (Beth Hughes, 11:30 am)

FYSM 1900 J (Rosie Kerr)

FYSM 1900 I (Kory Smith)

CIED 1001 A (Jen Gilbert, Tuesday)

CIED 1001 B (Jen Gilbert, Wednesday)

ESPW 1000 A (Workshop for ANTH 1002, Facil: Melanie)

ESPW 1000 B (Workshop for PHIL 1301, Facil: Kay)

ESPW 1000 D (Workshop for COMS 1002, Facil: Danielle)

ESPW 1000 F (Workshop for ENST 1020, Facil: Leah)

ESPW 1000 H (Workshop for HRSJ 1102, Facil: Marissa)

ESPW 1000 I (Workshop for LAWS 1002 B, Facil: Milan)

ESPW 1000 J (Workshop for PSCI 1100, Facil: Anya)

ESPW 1000 K (Workshop for PSYC 1002, Facil: Sarah)

ESPW 1000W L (11:35am workshop for MATH 1104, Facil: Hugo)

ESPW 1000 M (Workshop for PSYC 1002, Facil: Liv)

ESPW 1000 N (Workshop for PSYC 1002, Facil: Saghar)

ESPW 1000 O (Workshop for SOCI 1002, Facil: Inaya)

ESPW 1000 Q (Workshop for PSYC 1001, Facil: Megan)

ESPW 1000 S (Workshop for NEUR 1203, Facil: Aurora)

ESPW 1000 T (Workshop for ECON 1002, Facil: Andrew)

ESPW 1000 U (Workshop for COMP 1006, Facil: Manuel)

ESPW 1000 V (Workshop for CHEM 1002, Facil: Sumaya)

ESPW 1000 W (Workshop for MATH 1107, Facil: Jada)

ESPW 1000 X (Workshop for HIST 1901, Facil: Leslie)

ESPW 1000 Y (2:35pm workshop for CRCJ 1000, Facil: Gurleen)

ESPW 1000 Z (Workshop for LAWS 1002 C, Facil: Avery)

ESPW 1000 ZB (Workshop for BUSI 1800, Facil: Ellie)

ESPW 1000 ZD (8:35am workshop for MATH 1104, Facil: Hugo)

Reason for absence(Required)

Note: Medical self-declaration is for short-term illness only. For absence due to chronic illness or disability, you must seek accommodation from the Paul Menton Centre.

Absences will not be excused for transit/travel, competing deadlines, employment, or family/social obligations.

ESP accommodates varsity athlete absences for games, but not practices. For game-related absences (travel or game day), athletes must provide their game schedule to the ESP main office to have their absences excused.

Date of absence(Required)

Please write down the date you missed/will miss the ESP course or workshop(s) listed above.

Confirm each of the following with a checkmark.(Required)

I certify that I missed/will miss the ESP course or workshop(s) listed above due to short-term incapacitation as described above. I understand and acknowledge that providing false or misleading information is a violation of section VI.4 of the Academic Integrity Policy and is subject to an Academic Integrity review.

I understand that missing the ESP course or workshop(s) above may result in a negative impact to my academic performance. I will consult with an academic advisor as needed and be sure that I am aware of the academic withdrawal deadline and, as always, assess my continuation in my courses before that deadline.

I certify that I have read all of the above information and followed all of the steps indicated.

By submitting this form, I acknowledge that this is a request and that it is not automatically approved.

Consent(Required)

I agree to the privacy policy. Personal information collected through this application will be used and disclosed by Carleton University under the authority of the Carleton University Act, 1952, and in accordance with sections 39, 41 and 42 of Ontario’s Freedom of Information and Protection of Privacy Act. The purpose of this processing is to administer the Enriched Support Program. We may share some of the information provided with the appropriate internal personnel to assist with program delivery. We may also follow up at a later date to obtain your feedback and opinions concerning the ESP, or to discuss enrolment opportunities into a post-secondary educational program offered by Carleton University. If you have any questions about the processing of personal information by Carleton University, please contact the Manager, Privacy & Access to Information, by phone at 613-520-2600 ext. 2047 or by e-mail via University_Privacy_Office@carleton.ca.

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