MEDICAL OPINION ON THE STATE OF HEALTH OF A

CONTRACTOR SAFETY PROGRAM MANUAL FOR STOWERS INSTITUTE FOR MEDICAL
DATE ATTN MEDICAL DIRECTOR PHYSICIAN NAME MD INSTITUTIONINSURANCE COMPANY
RESOLUTION  (A11) PAGE 3 OF 4 AMERICAN MEDICAL

RESOLUTION 904  (I06) PAGE 2 AMERICAN MEDICAL ASSOCIATION
COLLEGE OF HEALTH RELATED PROFESSIONS CONTINUING EDUCATION MEDICAL
CONDITION SPECIFIC MEDICAL ADVICE FORM FOR A STUDENT

ORZECZENIE LEKARSKIE O STANIE ZDROWIA STUDENTA POLITECHNIKI WROCŁAWSKIEJ UBIEGAJĄCEGO SIĘ O URLOP ZDROWOTNY


MEDICAL OPINION ON THE STATE OF HEALTH OF A STUDENT OF WROCŁAW UNIVERSITY OF SCIENCE AND TECHNOLOGY APPLYING FOR A MEDICAL LEAVE




I. STUDENT’S PERSONAL INFORMATION - to be filled out by the student

First name and surname


Date of birth


PESEL (personal identification number)














Place of residence

Street

Street no.

Flat no.

Post code











Faculty



Academic year

Year of study

Semester

Grade book no.









City and date



Signature






MEDICAL OPINION IS ISSUED UPON THE REQUEST OF THE STUDENT APPLYING FOR A MEDICAL

LEAVE FOR THE PURPOSE OF SUBMISSION TO THE FACULTY’S DEAN


Stamp of the health facility issuing the opinion






II. MEDICAL OPINION - to be filled out by the doctor

The patient


visited the health facility on ..................


to obtain a medical opinion on his/her state of health due to his/her applying for a medical leave.

In the period from


to


he/she obtained


days of medical leave.

On the basis of medical documentation and a health examination, it has been found that a medical leave is

JUSTIFIED

UNJUSTIFIED

Suggested duration of medical leave

from


to









City and date







Doctor’s signature and stamp






__________________

*delete as appropriate


HOSPITAL MEDICAL STAFF POLICY SUBJECT DISRUPTIVE BEHAVIOR
HSR PLAZA II 4100 MEDICAL PARKWAY CARROLLTON TEXAS
MEDICAL PERSONNEL DEPT 8 BEECH HILL ROAD


Tags: health of, a health, state, medical, opinion, health