Spring 2021 COVID-19 Academic Year Absence Reporting Form
Students who have experienced a fever, chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, congestion or runny nose, sore throat, nausea, vomiting, diarrhea or who have been on a cruise ship in the past 30 days or have traveled outside the US within the past 14 days must contact HR@methodistcol.edu AND complete this form before coming to campus. In addition, students who have been advised to self-isolate by a healthcare provider must complete it before coming to campus. Human resources personnel will advise students about next steps.

Students who will miss any learning experience, including class, clinical, practicum, externship, internship, field placement, or internship are responsible to notify their faculty AS INDICATED IN THE SYLLABUS FOR THE COURSE. THEY MUST ALSO COMPLETE THIS FORM.

PLEASE NOTE: STUDENTS MUST ADHERE TO THE REQUIREMENTS IN THE SYLLABUS FOR THE COURSE. Students in a clinical/lab/field placement/practicum/internship course will not be permitted to miss a majority of these experiences unless it is due to a documented medical limitation (Healthcare Provider Required). This restriction will not apply if the Governor or Health Department of the State of Illinois places higher education under a restriction, such as a return to Level 3 of the Restore Illinois Plan.
NOTE: Nursing majors are required to meet the minimum number of clinical hours as required by the Illinois Department of Finance and Professional Regulation (IDFPR) and the Illinois Board of Nursing (IBON). Dean Ferguson will provide necessary information to students as needed.
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Last Name *
First Name *
Email Address *
Best Phone Number *
Rationale for Absence *
Explanation for absence or concern noted above, including explanation for "other" *
Start Date for Absence *
MM
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DD
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YYYY
End Date for Absence (these will be approved by faculty on a month-by-month basis, so please choose a date not later than one month from the date you are completing this form. Note to nursing majors: regulations from IDFPR and IBON must be met). *
MM
/
DD
/
YYYY
Course 1: List faculty, course name, number, and section below *
Course 2: List faculty, course name, number, and section below
Course 3: List faculty, course name, number, and section below
Course 4: List faculty, course name, number, and section below
Course 5: List faculty, course name, number, and section below
Typed Name - by typing my name below I confirm that the information is true and authorize the Dean of the Division or the Administrative Assistant to the Deans and Faculty to share the information with my faculty member and Methodist College HR. *
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