Student Nurse Excusal Form

Student Nurse Excusal Form

Student Information

Student Name:

Clinical / Practice Assignment

Clinical Site:

Course / Rotation:

Scheduled Clinical Date(s): From to

Reason for Excusal

Select reason(s) for request (check all that apply):

Medical condition or treatment requiring absence
Personal emergency / family obligation
Academic conflict (exam or required activity)
Other (provide explanation below)

Medical Certification (if applicable)

If the excusal is for medical reasons, a licensed health care provider must complete the section below or submit equivalent documentation on official letterhead that includes diagnosis, functional limitations, and recommended period of excusal.

Provider indicates student is unable to attend clinical/practice:

Student / Parent Acknowledgments

By signing below, the signer certifies the following:

I understand that excused absences may require make-up clinical hours, remediation, or alternate assignments at the discretion of the program and that make-up scheduling is the student's responsibility.
I acknowledge the school and clinical site will take reasonable steps to facilitate accommodations but are not liable for outcomes related to missed clinical experience beyond documented remedial requirements.
I authorize release of relevant medical information between the treating provider and the nursing program for the purpose of evaluating this excusal request.

Administrative Use Only

Decision: Approve Deny

Certification and Signature

I certify that the information provided on this form is true and accurate to the best of my knowledge. I understand that falsification of information may result in disciplinary action under program and institutional policies. I consent to the exchange of information between the program and my health care provider as necessary to evaluate this request and determine reasonable accommodations.

Sign Now