The document is a health professional report form for a university to assess how a student's health condition has impacted their studies. A treating health professional must complete the form to verify the student's condition and how it has significantly disadvantaged their ability to complete assessments. The form collects details of the condition's impact, dates of effect, and contact information for the university to verify the report if needed.
The document is a health professional report form for a university to assess how a student's health condition has impacted their studies. A treating health professional must complete the form to verify the student's condition and how it has significantly disadvantaged their ability to complete assessments. The form collects details of the condition's impact, dates of effect, and contact information for the university to verify the report if needed.
The document is a health professional report form for a university to assess how a student's health condition has impacted their studies. A treating health professional must complete the form to verify the student's condition and how it has significantly disadvantaged their ability to complete assessments. The form collects details of the condition's impact, dates of effect, and contact information for the university to verify the report if needed.
The document is a health professional report form for a university to assess how a student's health condition has impacted their studies. A treating health professional must complete the form to verify the student's condition and how it has significantly disadvantaged their ability to complete assessments. The form collects details of the condition's impact, dates of effect, and contact information for the university to verify the report if needed.
INSTRUCTIONS TO STUDENTS INSTRUCTION TO HEALTH PROFESSIONALS
This Health Professional Report (HPR) can only be completed Thank you for providing information to assist The University of and signed by a treating practitioner who can verify a health Melbourne assess the impact of this student’s circumstances on condition which they are qualified to authenticate. The treating their studies. The information you include on this form will be practitioner should be registered with the Australian Health used to verify the student’s application for special consideration Practitioner Regulation Agency (AHPRA) or Australian Association and to help determine reasonable adjustments to their of Social Workers (AASW). All relevant sections of this form must assessment/s. be complete for your application to be considered. An incomplete HPR may result in your application being ineligible. By completing and signing this form, you are verifying that: • the student has been affected by a health condition 1. Before completing this form, please read the University’s Special Consideration guidelines at: • you are not a family member or a close association of the student go.unimelb.edu.au/zd6r • you are registered with AHPRA or AASW and qualified to authenticate the student’s health condition 2. If your circumstances are affecting upcoming or overdue assessment tasks: • staff at the University of Melbourne can contact you to • Please ask your treating practitioner to complete this form. verify the authenticity of this document • Submit an application for “Special Consideration (Unexpected Circumstances)” online and upload a Student Name: signed copy of this form.
3. If your circumstances are affecting your study for longer than Date of birth: D D / M M / Y Y Y Y
six weeks: • Please also consider submitting an application for “Special I have assessed that the student has been hampered, to a Consideration (Ongoing Support)” online. significant degree, by health condition or exceptional situation • Your health professional will need to complete a from undertaking or preparing for their academic assessment “Registration for Ongoing Support” form. task(s).
4. Your personal information is managed under the Privacy and (Estimated) Start Date: D D / M M / Y Y Y Y Data Protection Act 2014 (Vic) and the Health Records Act 2001 (Vic). All personal information collected by the University is governed by the University’s Privacy Policy at: (Estimated) End Date: D D / M M / Y Y Y Y
policy.unimelb.edu.au/MPF1104 OR
Unclear/Ongoing* By signing this document, I declare that all the information supplied by myself and the health professional is complete, true and correct in every particular and acknowledge that the University may terminate my studies if I have misrepresented my past and/or * In the case of ongoing impact, the student can also register for present circumstances and that this termination may take place at any stage during the ongoing support: course undertaken. I understand that the University reserves the right to inform other tertiary institutions if any of the material presented to support my application is found to go.unimelb.edu.au/mb4x be false. All documents submitted become the property of the University of Melbourne. I give permission for the University of Melbourne to contact my health professional to verify the information on this form if needed, and for relevant information to be provided by my health professional to the University of Melbourne.
Student number: 1 2 3 4 5 6 7
Name:
Signature:
Date: D D / M M / Y Y Y Y
FURTHER INFORMATION Please contact the Student Equity and Disability Services team t: +61 3 8344 0836 e: equity-disability@unimelb.edu.au
Version 2.0 - Last Modified: June 5, 2019 12:29 PM | The University of Melbourne - CRICOS Provider Code: 00116K 1 of 2 Health Professional Report UNEXPECTED CIRCUMSTANCES
DETAIL OF IMPACT Additional documentation can also be attached to this form if required.
Does the student’s condition significantly disadvantage of impact their ability to undertake the following types of assessment? (please tick as applicable)
Written assessment (e.g. essay/assignment) Examination Take home examination
Clinical Placement or lab work with Presentation Performance (e.g. recital)
hazardous material
Professional placement Other (please specify):
Please describe how the student’s circumstances impact on their ability to complete, attend or prepare for the academic assessment task/s by the designated deadline/s.
If this medical assessment has occurred 4 days after the due date of academic assessment, based on your professional opinion or advice please outline why the student was unable to apply on time.
Practitioner’s Professional Name: Practitioner’s Stamp: Registration no.:
Address of practice:
Telephone no.:
Signature:
Date: D D / M M / Y Y Y Y
Privacy statement The collection of personal information by the University of Melbourne (University) is governed by the Privacy and Data Protection Act 2014 (Vic) and Health Records Act 2001 (Vic) (together, Privacy Laws). The University is also considered to be a data controller for the purposes of the EU General Data Protection Regulation 2016/679 (GDPR) in relation to the collection of personal information from individuals located in the EU. The University is committed to protecting your privacy and processing your personal information fairly and lawfully in compliance with the Privacy Laws and the GDPR, as applicable. The University is requesting the information on this form to assess the impact of a student’s circumstances on their studies. You can contact us at equity-disability@unimelb.edu.au or on +61 3 8344 0836. Further details about how we handle your personal information can be found in our Student privacy statement (https://about. unimelb.edu.au/strategy/governance/compliance-obligations/privacy/privacy-statements/student-privacy-statement)
Version 2.0 - Last Modified: June 5, 2019 12:29 PM | The University of Melbourne - CRICOS Provider Code: 00116K 2 of 2
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