MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES

OFFICE OF THE DEAN OF STUDENTS

STUDENTS SERVICS BUREAU

SICK SHEET FORM

(To be filled in by sick/out-patient student only)

1.1 Name of Hospital/Health Centre/Clinic/Dispensary …………………………..……………....
1.2 Name of Student …………………………………….……………………………………...…
1.3 Sex ………………………………………………………..……………………………………
1.4 Registration Number ……………………………………….…………………………...……..
1.5 Course/Year …………………………………………………………….……………......……
1.6 Residential Place …………………………………………………………….……………..….
1.7 Mobile Number …………………………………… Signature: ……………………………...
1.8 Name of next of kin ……………………….………. Mobile Number ……..…………..……..

(To be filled in by Medical Officer/Clinician)

2.1 The number of Light Duty/Excuse Duty (ED) granted ………….……….…..... (If applicable)
From ………………………..……...……… to ……………………………………..……..
2.1.1 Reason for Light Duty/ED …………………………………………………………………...
2.2 Name of attending Clinician ……………………………………………………..………...…..
2.3 Qualification ………………………………..… Mobile Number ………..……………………
2.4 Facility Contact Number ………………….……………………………………………………

2.5 Signature ………………......…… Stamp …………………..… Date …….……………..……

(To be filled in by Students Services Bureau Office-MUHAS)

3.1 The student attended to the hospital on …………………………………………………...……
3.2 Name of a Janitor/Warden ………………………..………………....…………………….…...
3.3 Mobile Number ……………………………………………………………………………...…

3.4 Signature ………………...…… Stamp ……………………..… Date ………………….…….