HERIOT-WATT MANAGEMENT PROGRAMME

School of Management and Languages

Medical Certificate Form
If you have missed or will miss your examination(s) due to medical reasons please complete this form. Your Medical
Practitioner must complete Section A (below).
PERSONAL DETAILS
Registration Number
Title (Mr/Miss/Mrs/Ms)

First Name

Surname / Last Name / Family Name

APPROVED LEARNING PARTNER (ALP) (please enter name or tick box)

or Independent Learner
Date(s) to which the form is to apply
Module Examination(s) for which the
form is to apply
SECTION A - To be completed by the Medical Practitioner
Name (please print)
Address
Date(s) to which the Medical Certificate(s) apply
MEDICAL PRACTICES STAMP

I, the undersigned, verify that the above named student sought medical assistance on the date specified on the
Medical Certificate and was diagnosed appropriately for their condition as stated on the attached Medical
Certificates.
The above named student was/was not* capable of undertaking the examinations as stated in the date(s) to which
the Medical Certificate is to apply. (*Delete as appropriate)
Signature

Date

STUDENT DECLARATION (STUDENTS MUST SIGN THIS BEFORE SUBMITTING)

I, the undersigned, verify that the information provided in this form, and in the Medical Certificate is an accurate
record of my circumstances and complies with the Management Programme policy on Mitigating Circumstances:
Signature

Medical Certificate attached:

Heriot-Watt University: Heriot-Watt Management Programme

Medical Certificate Form (June 2010)

Date

Yes

No

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HERIOT-WATT MANAGEMENT PROGRAMME

School of Management and Languages
Policy on Medical Certificates
The School of Management & Languages has set out the following procedures that must be adhered to by
all students submitting this form prior to and at examination diets for the Heriot-Watt Management
Programme:
As per Regulation 9 (new) of Heriot-Watt University: A candidate who is prevented through illness
from taking an examination shall submit to the [Management Programme] a certificate issued by
a registered medical practitioner.
1. Completed forms, with medical certificate, must be submitted within two weeks of the end of the
examination diet, that is by the second Friday following the examination week. It is the students
responsibility to ensure that the External Programmes receive it by then.
2. Students must complete the form fully, ensuring all relevant sections have been completed.
3. Students must indicate to which module examination(s) their Medical Certificate is to apply.
4. Section A of the Medical Certificate Form must be completed, signed, dated and stamped by
the Registered Medical Practitioner (Doctor/Medical Specialist/Nurse).
5. Medical Certificates must be signed and dated by the Registered Medical Practitioner
(Doctor/Medical Specialist/Nurse). It must also be stamped with the medical practitioners seal.
6. Any Medical Certificate must be submitted with a completed Medical Certificate form. A Medical
Certificate not accompanied by the completed form will not be accepted.
7. Medical Certificates must be the original. Photocopied or faxed versions are not permitted and
will not be accepted by the Board of Examiners.
8. The Registered Medical Practitioner is required to indicate whether the student is capable, or
otherwise, of undertaking an examination and verify the dates to which the student was incapable
of undertaking the examinations. If this is not indicated, the Medical Certificate will not be
accepted.

RETURN FORM TO:

External Programmes, Mary Burton Building - Room G47, School of Management and
Languages, Heriot-Watt University, Riccarton, Edinburgh, EH14 4AS, Scotland, UK

Heriot-Watt University: Heriot-Watt Management Programme

Medical Certificate Form (June 2010)

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