Duke University. Trinity College of Arts & Sciences/ Pratt School of Engineering Application for Readmission to Duke

Transcription

1 Office Use Only Durham, North Carolina Application Fee $30 received Trinity College of Arts & Sciences/ Pratt School of Engineering Application for Readmission to Duke BEFORE completing this application, please review the RETURNING STUDENT CHECKLIST. Visit the website at to download a copy. This application is not appropriate for students returning from a personal leave of absence or an administrative financial withdrawal. PART A: STUDENT DATA Date of application: / / Date of withdrawal: / / (mm) (dd) (yyyy) (mm) (dd) (yyyy) Desired term of readmission: Fall Spring Summer I/II (Deadline: July 1) (Deadline: November 1) (Deadline: April 1) Where were you enrolled at the time of your separation from Duke? Trinity Pratt Office Use Only: Date statement received Prior time away from Duke Term Term status status How many semesters were you enrolled at Duke (regardless of your performance)? Term status Please check an appropriate response: Are you requesting to be readmitted to Pratt School of Engineering NO Yes Are you requesting to be readmitted to Trinity College of Arts and Sciences NO Yes Check all that apply. You are returning from a: 1 st Academic Dismissal 1 st Disciplinary Dismissal 1 st Medical Leave of Absence 2 nd Academic Dismissal 2 nd Disciplinary Dismissal 2 nd Medical Leave of Absence Voluntary Withdrawal 3 rd Disciplinary Dismissal 3 rd Medical Leave of Absence Administrative Withdrawal (failure to comply, non-financial) PLEASE PRINT OR TYPE BELOW Falsification of any part of your return application will result in you being referred to the Office of Student Conduct for official disciplinary inquiry, denied readmission for the requested term, and likely permanent ineligibility to return to Duke. 1. Your full name Last First Middle Jr., III 2. Social Security Number (last four digits) 3. Current or home address: (street) 4. Original matriculation year at Duke: (city) (state) (zip) (country) ( ) (phone)

2 5. If readmitted, what is your new expected date of graduation 6. Prior to your dismissal, did you hold a J1 or F1 visa Yes No International students are advised to contact Duke Visa Services immediately regarding their intention to return to Duke. claudia.delacruz@duke.edu. 7. Do you intend to apply for financial aid? Yes No 8. Indicate status of major at time of withdrawal: Undeclared Declared If declared, which area? 9. If major was declared, will it remain the same? Yes No If no, give desired new major: 10. Do you have any disciplinary action(s) pending at in the Office of Student Conduct? yes no 11. During your time away from Duke, has any criminal and or civil action been taken (or is pending) against you? yes no If yes, please attach a separate statement of explanation. 12. If you have completed any academic work while away from Duke, list in order, beginning with present or most recent, all colleges and universities attended together with dates of attendance. Please note that you are not eligible to receive credit for course work completed during an academic dismissal or disciplinary dismissal period. (name of school) (mm/yyyy) (mm/yyyy) (name of school) (mm/yyyy) (mm/yyyy) (name of school) (mm/yyyy) (mm/yyyy) 13. List in order, beginning with present or most recent, all employment and/or volunteer or internship activities, along with start and end dates, since leaving Duke. (See SHEET OF INSTRUCTIONS, EMPLOYMENT LETTERS) (name of co./organization) (mm/yyyy) (mm/yyyy) (name of co./organization) (mm/yyyy) (mm/yyyy) (name of co./organization) (mm/yyyy) (mm/yyyy) 14. List names and positions of person(s) who will submit recommendations on your behalf. Any health care provider submitting a recommendation must be listed. Please indicate if you have signed a release of information with each health care provided listed allowing them to speak with members of your review committee regarding your return to Duke. Signed release of information is on file? yes no n/a (name) (position) (organization) yes no n/a (name) (position) (organization yes no n/a (name) (position) (organization) yes no n/a (name) (position) (organization)

3 15. Prepare a thoughtful personal statement: Provide a detailed statement outlining your experiences at Duke and the circumstances that led to your separation. Explain how you have spent your time away from Duke (e.g. medical treatment, paid/volunteer work, academic course work, other activities) and how these experiences have been productive and helpful to your understanding of what changes must be made in order for you to succeed as a Duke student. If you received medical treatment, list the medical, psychological or health professionals you have seen, and the number of visits to each. List any drugs that you are taking for this problem, the side effects that you have encountered that might affect your ability to attend and complete classes (e.g. drowsiness, inability to concentrate), and any modifications you intend to make in your schedule and or behavior when you return. Describe your plans (if any) for continuing to work with a health professional after you return to Duke.

4 Durham, North Carolina Trinity College of Arts & Sciences/ Pratt School of Engineering Work Recommendation for Readmission (please make as many copies as you need of this sheet) TO THE APPLICANT: Fill in your name and forward this form to your recommender. For the convenience of the recommender, you should include a stamped addressed envelope. This form must accompany the submitted recommendation letter. RECOMMENDATION ON BEHALF OF: Student s Name (please print) APPLICANT S WAIVER OF RIGHT OF ACCESS TO CONFIDENTIAL STATEMENT: I hereby voluntarily waive my right of access to any information contained on the recommendation form and agree that the statement will remain confidential. (student signature) (date) Only the recommender should write in this section. TO THE RECOMMENDER: Please attach a letter confirming the dates during which the applicant has worked under your supervision. We ask that you comment on the applicant s character and work habits as well as the quality of work performed. The review committee will consider your recommendation when evaluating the applicant s request for readmission. Due to federal legislation which allows students access to view their records, cannot guarantee the confidentiality of your statement unless the applicant has signed the waiver printed above. Candidate provided this form to me on. please indicate date THIS RECOMMENDATION LETTER WAS WRITTEN BY: Print recommender s name Professional position/title Please mail directly to the following address: Regular postal mail: overnight/express service ONLY: 011 Allen Building Box Durham, NC Durham, NC Please DO NOT RETURN your completed recommendation TO THE APPLICANT. This COVER LETTER MUST ACCOMPANY YOUR RECOMMENDATION LETTER.

5 Durham, North Carolina Trinity College of Arts & Sciences/ Pratt School of Engineering Professor s Recommendation for Readmission (Please make as many copies as you need of this sheet.) TO THE APPLICANT: Fill in your name and forward this form to your recommender. For the convenience of the recommender, you should include a stamped addressed envelope. This form must accompany the submitted recommendation letter. RECOMMENDATION ON BEHALF OF: Student s Name (please print) APPLICANT S WAIVER OF RIGHT OF ACCESS TO CONFIDENTIAL STATEMENT: I hereby voluntarily waive my right of access to any information contained on the recommendation form and agree that the statement will remain confidential. (student signature) (date) Only the recommender should write in this section. TO THE RECOMMENDER: Please attach a letter confirming the dates during which the applicant was enrolled in your course. We ask that you comment on the applicant s overall classroom citizenship (e.g., arrival, attendance, participation, deadline submission, quality of work performed). The review committee will consider your recommendation when evaluating the applicant s request for readmission. Due to federal legislation which allows students access to view their records, cannot guarantee the confidentiality of your statement unless the applicant has signed the waiver printed above. Candidate provided this form to me on. please indicate date THIS RECOMMENDATION LETTER WAS WRITTEN BY: Print recommender s name Professional position/title Please mail directly to the following address: Regular postal mail: overnight/express service ONLY: 011 Allen Building Box Durham, NC Durham, NC Please DO NOT RETURN your completed recommendation TO THE APPLICANT. This COVER LETTER MUST ACCOMPANY YOUR RECOMMENDATION LETTER.

6 THIS BEGINS PART B OF THE RETURN APPLICATION PART B MATERIALS ARE APPLICABLE ONLY FOR Students Returning From A MEDICAL LEAVE OF ABSENCE OR Any student whose separation from Duke was caused by a health related concern for which they were advised to seek treatment while away. For example: Students who were academically dismissed, suspended or withdrawn and advised to seek treatment for substance abuse. Students who were academically dismissed, suspended or withdrawn and advised to seek treatment related to emotional or mental health concerns. Students who were academically dismissed, suspended or withdrawn and advised to seek treatment related to any type of physical injury. Students who were academically dismissed, suspended or withdrawn and advised to seek treatment related to a chronic illness.

7 Durham, North Carolina Trinity College of Arts & Sciences/ Pratt School of Engineering Application for Readmission to Duke PART B: MEDICAL DOCUMENTS HEALTH Recommendation for Readmission (please make as many copies as you need of this sheet) TO THE APPLICANT: Fill in your name and forward this form to your recommender. For the convenience of the recommender, you should include a stamped addressed envelope. This form must accompany the submitted recommendation letter. RECOMMENDATION ON BEHALF OF: Student s Name (please print) APPLICANT S WAIVER OF RIGHT OF ACCESS TO CONFIDENTIAL STATEMENT: I hereby voluntarily waive my right of access to any information contained on the recommendation form and agree that the statement will remain confidential. (student signature) (date) Only the recommender should write in this section. TO THE RECOMMENDER: Please attach a letter confirming the dates during which the applicant was under your care. We ask that you comment on the applicant s health concerns, treatment plan while away, compliance, future treatment recommendations, readiness to return to full-time (four course credits) academic studies. The review committee will consider your recommendation when evaluating the applicant s request for readmission. Due to federal legislation which allows students access to view their records, cannot guarantee the confidentiality of your statement unless the applicant has signed the waiver printed above. Candidate provided this form to me on. please indicate date THIS RECOMMENDATION LETTER WAS WRITTEN BY: Print recommender s name Professional position/title Please mail directly to the following address: Regular postal mail: overnight/express service ONLY: 011 Allen Building Box Durham, NC Durham, NC Please DO NOT RETURN your completed recommendation TO THE APPLICANT. This COVER LETTER MUST ACCOMPANY YOUR RECOMMENDATION LETTER.

8 COVER LETTER TO THE HEALTH PROFESSIONAL: You are currently treating a student who wishes to return to from a Medical Leave of Absence. We are asking you to write a letter to the student s review committee and provide the information requested below, so that we can determine if the student has recovered sufficiently to resume academic responsibilities at Duke. We also ask that you fill out the attached brief questionnaire regarding your treatment of the student and any continued care recommendations. Please return your letter and questionnaire to: Regular postal mail: Express service ONLY: Box Allen Building Durham, NC Durham, NC or fax it to Send your letter between October 1 and November 1 if the student plans to return for the spring semester, between March 1 and April 1 for a return for the summer session, and between June 1 and July 1 for the fall semester. If you have any questions, please contact Dean Thomas at or officeofstudentreturns@duke.edu. Thank you for your help. CHECK LIST Describe the problem(s) that led this student to take a Medical Leave of Absence. Provide your opinion as to whether the student is able to return to Duke at this time and successfully engage a full course load (of four semester credits). If student is not ready to return in a full course load, will an additional term away better prepare the student to engage in a full course load? List any medications that you have prescribed for this student, any side effects that may affect the student s ability to attend and complete classes, whether any prescribed medications need to be monitored, and name of treatment provider monitoring this medication.

9 TREATING DOCTOR S RE-ENTRY QUESTIONNAIRE Instructions: This form is to be completed by the treating physician, other M.D., or licensed mental health provider. It will be reviewed by the appropriate licensed Duke Health professional. Your assessment is important. The student s application will not be reviewed without your submitted materials. Please respond to the questions listed below and attach a brief statement of recommendation for re-entry and a treatment summary on your office letterhead. Send the completed form and statement directly to:,,, Box 90052, Durham, NC Materials may also be faxed to Address questions to officeofstudentreturns@duke.edu This form must be submitted by the health care provider directly to the. Please Respond to All Questions Full name of patient: Are you a: Psychiatrist Other M.D. Licensed Mental Health Provider Did you provide treatment for the above named Patient? Yes No Please list the particular health conditions/concerns you diagnosed in your assessment of the patient along with treatment start date, end date, completion status and total treatment sessions. TREATMENT Start Date End Date Total Treatment Treatment Treatment Ended Sessions Completed? With Your Permission? Diagnosis #1 yes no yes no referral Diagnosis #2 yes no yes no referral Diagnosis #3 yes no yes no referral If you referred the patient for continuing treatment for any diagnosis, to whom did you make the referral? Diagnosis #1 Referred to: provider name professional title/position address Diagnosis #2 Referred to: provider name professional title/position address Diagnosis #3 Referred to: provider name professional title/position address

10 Please indicate any specific intensive treatment program in which student participated while on leave. If the patient has not completed treatment for the any diagnosis/condition listed above and a referral was not made, are you continuing to provide treatment? Yes No. Specify diagnosis If the patient has not completed treatment, how frequently will the patient need to see you? What are the continued care needs for this patient? If the patient is continuing treatment with you or someone else, do you believe he/she would be able to function appropriately as a student at this University without that continued treatment? Yes No In your care of this student, do you consider there to be any safety concerns? Yes No If yes, under what conditions could this be foreseeable? To your knowledge, are the parents and/or legal guardian(s) of the patient aware of the problem(s) for which you have provided treatment? Yes No Has the student signed, and placed on file in your home office, a release of information to allow you to speak directly with any member of the review committee regarding their readiness to return to Duke and continuity of care, should a conversation be requested? yes no Other comments: Signature of Treating Professional Name of Treating Professional (please print or type) Date Phone Number Address of Treating Professional This form must be submitted directly to the by the health care provider. Send the completed form and statement directly to:,,, Box 90052, Durham, NC Materials may also be faxed to Address questions to officeofstudentreturns@duke.edu.