Missed class documentation
PSYC 2220 – Sensation and perception I
Department of Psychology
York University
Fall term 2013
Instructor: Dr. Richard F. Murray, 416-736-2100 x 23025, rfm@yorku.ca
Part I – To be completed by the student
Student’s information
Name
_______________________________________
Student number
_______________________________________
Student missed (check all that apply)
 class
 quiz
 midterm test
 final exam
Reason for absence
 illness
 religious obligation
 family emergency
 other __________________________
Person providing confirmation
 physician
 religious official
 other ___________________
Name
____________________________________________
Address
____________________________________________
____________________________________________
Telephone number _____________________________
Part II – To be completed by person providing confirmation
Reason for student’s absence
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Do you think this would have seriously affected the student’s ability to attend class
or write a test? (It is not necessary to answer this question if the reason for
absence is a religious obligation.)
Circle one:
yes
no
Dates during which the event required the student to miss class
Start date: ______________________ End date: ______________________
Name and signature of person providing confirmation
________________________________
Name
____________________________
Position
________________________________
Signature
____________________________
Date