Explanatory Statement for Absence from Class – Tier 1

Student Information:

Last Name: First Name:

Student ID #:

Email:

Dates Missed:

Begin date: End Date:

Course Information:

Department, Course and Section:

Name of Instructor:

Reason for Absence:

Please give, if possible, the name of someone who can vouch for your illness:

Name:

Address:

Phone number: Email:

To the best of my knowledge and belief, by signing below I certify that the above
statements are true, and I acknowledge that my instructor may or may not accept
this form as verification of an excused absence.

Signature:

This form can be used by UK students to communicate with professors regarding illness/injury which
prevents class attendance, but does not warrant a visit to the medical clinic per UHS policy “Class
Attendance and Verification of Visit”. Students can complete this form and submit to applicable
professors via hardcopy or email. This completed form is NOT saved or viewed by UHS. In an effort to
teach students appropriate healthcare consumerism, UHS staff respectively requests UK faculty to
refrain from requiring students to visit the medical clinic for a Verification of Visit for minor illnesses.
However, instructors have the right to determine the type of documentation that constitutes
verification of an excused absence. Please speak with your instructor and/or check your syllabus to
determine if this form will be accepted as verification of an excused absence by your instructor.

University Health Service

University of Kentucky ● 830 South Limestone Street ● Lexington, KY 40536‐0582
Phone: (859) 323‐5823 ● Fax: (859) 323‐1119 ● www.ukhealthcare.uky.edu/uhs