Medical Excuse Template - City Of Memphis printable pdf download

Medical Excuse Template - City Of Memphis

City of

MEDICAL EXCUSE

Memphis

Doctor’s Name:

__________________________________________

Doctor’s Address:

__________________________________________

Doctor’s Phone No.: __________________________________________

This is to certify that: _________________________________________________

was seen at my office on _________________. This individual was experiencing pain or

the following general symptom(s):

As a result the individual could not perform the following functions of his/her job:

________________________________________________________________________

It is expected the individual will be able to return to work on: __________________

__________________________________

Doctor’s Signature

Date:

This optional form should be used when an employee is absent on sick leave for 3 or more days.

Pursuant to City policy PM 46-03: an employee may be absent from work on sick leave up to three

(3) consecutive days before medical documentation is required. However, if an employee shows a

pattern of abuse as set forth in the Policy Statement of PM 46-03, the employee may be required to

present medical documentation for his/her sick leave absence prior to three (3) consecutive days of

absence.

Medical Excuse Template - City Of Memphis