Health Services
This form does not require disclosure of your medical diagnosis or condition. You will not be asked to share sensitive medical details here. If supporting documentation is required, the Office of Institutional Research & Effectiveness will contact you separately. Your information is protected under FERPA and HIPAA.
Need immediate support? If you are experiencing a mental health crisis or medical emergency, please contact Student Health Services, Campus Safety, or call 911 before completing this form. This form is for administrative leave processing only.
Section 1 — Student Information
First Name:*
Please enter your first name.
Last Name:*
Please enter your last name.
Student ID:*
Please enter your student ID.
SWAU Email:*
Please enter a valid email address.
Major / Program:*
Please enter your major or program.
Classification:*
Please select your classification.
Phone Number:
Section 2 — Leave Details
Term Requesting Leave:*
Please select the term.
Leave Type:*
Please select a leave type.
Requested Start Date:*
Please select a start date.
Expected Return Date:
Leave blank if unknown at this time.
Section 3 — Academic Impact
Withdrawal: (optional)
You may skip this field if you are unsure. The reviewing office will follow up with you regarding withdrawal options.
ⓘ Important — Steps You Are Responsible For As part of your Medical Leave of Absence, the following steps are your responsibility to complete independently. OIRE does not coordinate these on your behalf:
- Contact Academic Advising to discuss the impact on your degree plan and course progression.
- Contact the Financial Aid Office to understand how your leave may affect your aid, scholarships, or loan status.
- Contact Student Housing if you reside on campus to arrange housing adjustments.
- Plan your return to enrollment by contacting the Registrar's Office before your intended return term.
Section 4 — Additional Context (optional)
⚠ Supporting Documentation Required Depending on the nature of your request, you will likely need to provide a physician's note, hospital documentation, or other medical verification. Before you click Send in Outlook, please attach your documentation directly to the email. Accepted file types: PDF, JPG, PNG, Word document. If you do not have documentation ready at the time of submission, you may email it separately — please include your full name and student ID so it can be matched to your request.
Please do not include your medical diagnosis or condition name in the text field below. This is for general context only.
Please do not include your medical diagnosis or condition name in the text field below. This is for general context only.
Section 5 — Acknowledgment — all three required
⚠ You must check all three boxes below before your request can be submitted.
⚠ All three acknowledgment statements must be checked before you can submit.
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Clicking Submit Request will open your email client pre-filled and addressed to the Office of Institutional Research & Effectiveness. Before clicking Send, please attach your supporting documentation (physician's note, hospital record, etc.) directly to the email. If your email client does not open, use the Copy to Clipboard button below.
Your email client should now be open. Before clicking Send, please attach your supporting documentation (physician's note, hospital record, or other medical verification) to the email. Once sent, allow 3–5 business days for a decision from the Office of Institutional Research & Effectiveness.
Email client didn't open? Copy your request below and create a new email to sargeant@swau.edu.