Student Change in Status Form

Acknowledgement:*

I am the student submitting the change in status request.
I am a faculty or staff member submitting the change in status request on behalf of the student.

Your name:*

Student name:*

First Last

Date*

RVU ID Number:*

Program:*

Doctor of Osteopathic Medicine (DO)
Doctorate of Nurse Anesthesia Practice (DNAP)
Master of Physician Assistant Studies (PA)
Master of Science in Biomedical Sciences (MSBS) - Colorado and Utah only
Master of Medical Sciences (MMS) - MCOM

Additional Program Designations (check all that apply):

Track
Military
Fellow

What is the name of the Track and the Track Director?

Which class?*

OMS I
OMS II
OMS III
OMS IV

Campus:*

Colorado
Montana
Utah

Permanent mailing address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone number:

Email address:*

Type of change in status:*

What type of leave of absence?*

Voluntary
Administrative

Student has already met with Student Affairs:*

Yes
No

Date of meeting:*

Reason for request of intercampus transfer:*

Student is in good academic standing:*

Yes
No

Student is in good professional standing:*

Yes
No

Requested campus, program, and class year of transfer:*

CAMPUS	PROGRAM	CLASS YEAR

Student Affairs has confirmed that there is enough space in the campus, program, and class year of transfer:*

Yes
No

Effective date of transfer:*

Effective term:*

Fall
Spring
Summer

Effective year:*

Graduation date:*

Fellowship:*

Anatomy
MCOM Osteopathic Teaching Fellowship
OPP
Simulation
Pre-Doctoral Internship (PDI)
Research

Which COM year will you enter upon the start of the next academic year?*

OMS Year 3
OMS Year 4
OMS Year 5

Which fellowship year will you enter upon the start of the next academic year?*

1st year of fellowship requirements
2nd year of fellowship requirements
3rd year of fellowship requirements

What is your new anticipated graduation year?*

Leave of absence:

Proposed effective date*

When do you intend to return?*

Fall
Spring

Year of intended return:*

Why are you leaving RVU at this time?*

Academic Challenges
Medical Issues
Financial Reasons
Career Change
Family Related
Personal Issues
Military Related

I understand that I am responsible for all financial obligations and completing all academic requirements. I will complete this form again for reinstatement at least ten weeks prior to my return to ensure that my registration records are updated and I am included in appropriate future e-mail communications.

Complete withdrawal:

Proposed effective date*

From what semester and year are you withdrawing?*

Is this a voluntary or involuntary withdrawal?*

Voluntary
Involuntary

Year of matriculation:

Why are you leaving RVU at this time?*

Academic Challenges
Medical Issues
Financial Reasons
Career Change
Family Related
Personal Issues
Military Related

I understand that I am responsible for all financial obligations and that I will be required to apply for admission again if interested in returning to RVU in the future.

Reinstatement:

Returning semester:*

Which class do you anticipate joining?*

1st year
2nd year
3rd year
4th year

Did you have any change of name or change of address while you were on leave?*

Yes
No

Please explain:*

Attach additional explanation documentation, if needed.

Please do not attach legal documents or any other type of sensitive material.

Drop files here or

Max. file size: 10 MB.

Is there anything else that you would like us to know?

Signature*