Medical Leave of Absence (Mloa) Treatment Provider Report: SECTION I: To Be Completed by The Student

Deadlines for Return from MLOA
Term: Must submit by:

Fall AUG 1
Spring DEC 1
Summer APRIL 1
MEDICAL LEAVE OF ABSENCE (MLOA)

TREATMENT PROVIDER REPORT
SECTION I: To be completed by the student:
Please ensure this form is completed by any and all providers who provided treatment during the
MLOA dates listed below (i.e., primary care provider, specialist, psychiatrist, therapist, etc.). This form
must be completed in full and submitted to the Office of Student Care Coordination by the deadline in
the box above corresponding to the relevant term of return. Incomplete or late submissions may result in
a delay in re-enrollment until the next term pending submission and approval of new documents.
Student Name: Shubhankar Das Date of Birth: 10 /05 / 1999
Duration of Leave: 3 / 12 / 2020 to 8 /1 /2020
Term for which you are requesting to return from MLOA: Fall / 2020
Term Year
SECTION II: To be completed by licensed treatment provider:
The above-named student is seeking to return to Vanderbilt University after taking a medical leave of
absence. Please complete the following information, sign, and return this report to the Office of Student
Care Coordination using the contact information noted below. If necessary, attach additional documents
to expand on your recommendations and the student’s ability to function safely, stably, and successfully
as a full-time student at this time.
Treatment Information
Current Diagnosis(es): ________________________________________________________________
___________________________________________________________________________________
Date(s) of treatment: / / to / /
Total number of visits:
Was student compliant with treatment plan (If no, please explain)
Please provide details of treatment provided:
Current Medications:
Medication Date Started Dosage/Frequency Stable
Recommendations for continued medication management: ____________________________________
___________________________________________________________________________________
___________________________________________________________________________________
If not, have follow-up services been arranged for when this

Service/Provider Information:
Assessment of the Student:
If yes, please explain:
If yes, please explain:
What is your assessment of the current status of the student’s condition? Fair Poor
Has this student demonstrated an ability to maintain a schedule and function productively in
conjunction with or outside of the treatment program for at least 3 months? This could include holding
a full or part-time job, pursuing regular volunteer work, taking a college-level course, or other
productive activities.
If no, please explain
Do you have any reservations regarding this student’s full‐time enrollment in the rigorous academic
environment at Vanderbilt University in the upcoming semester?
No Reservations Reservations
Please explain:
Recommendations for Support Services:

Please indicate which of the following options would be beneficial for the student when they return to
campus and provide specific recommendations in the box below that will help the student succeed.
Check all that may apply. (Examples of specific recommendations may include: “Student would benefit from
biweekly CBT sessions for continued treatment of anxiety;” “Student would benefit from weekly AA meetings and
follow-up with psychiatry in 30 days for continued management of Celexa.”)
Specific Recommendations:
Psychological Counseling Psychiatric Follow up Eating Disorder Support

Group Individual
Drug and Alcohol Resources Primary or Specialty Nutritional Support
Medical Care
ADA Accommodations (if On-Campus Housing Special Needs Housing
recommended, additional
documentation will be required)
Reduced Academic Course Load
Have you discussed these
Is student in agreement with these recommendations?

MEDICAL CARE PROVIDER INFORMATION/SIGNATURE
(We may contact you with a request for more detailed information)
Provider name: ______________________________________________________________________
Credentials/Profession: License Number: ________________________
Area of Medical/Mental Health Specialty:
Address:
Phone: Email:
Signature: Date: / /
Please complete in full and return by mail, fax or email to:
Office of Student Care Coordination

ATTN: MLOA/Health Records
PMB 351508, 2301 Vanderbilt Place
Nashville, TN 37235-1508
Fax: (615) 343-3702
Email: [email protected]

Medical Leave of Absence (Mloa) Treatment Provider Report: SECTION I: To Be Completed by The Student

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Medical Leave of Absence (Mloa) Treatment Provider Report: SECTION I: To Be Completed by The Student

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Deadlines for Return from MLOA

Term: Must submit by:

MEDICAL LEAVE OF ABSENCE (MLOA)

Student Name: Shubhankar Das Date of Birth: 10 /05 / 1999

Duration of Leave: 3 / 12 / 2020 to 8 /1 /2020

SECTION II: To be completed by licensed treatment provider:

Current Diagnosis(es): ________________________________________________________________

Total number of visits:

Recommendations for continued medication management: ____________________________________

If not, have follow-up services been arranged for when this

Assessment of the Student:

If yes, please explain:

If yes, please explain:

If no, please explain

Recommendations for Support Services:

Psychological Counseling Psychiatric Follow up Eating Disorder Support

Have you discussed these

Is student in agreement with these recommendations?

Provider name: ______________________________________________________________________

Credentials/Profession: License Number: ________________________

Area of Medical/Mental Health Specialty:

Please complete in full and return by mail, fax or email to:

Office of Student Care Coordination

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