Employee Accident/injury/illness Report Form - Cohoes City School District (Page 3 of 3) in pdf

Employee Accident/injury/illness Report Form - Cohoes City School District Page 3

Consent to Develop Medical and Wage Information

________________________________________________________________________________________

“I hereby consent and request that the bearer be permitted to examine and obtain copies of all hospital and

medical records of every sort and kind, interview doctors and other attendants regarding all matters relating to

examination, diagnosis, care and treatment of myself. I further consent and request that the bearer be

permitted to interview and correspond with all employers and former employers regarding all matters relating

to my earnings and loss of earnings.

“I am willing that a photostat of this authorization be accepted with the same authority as the original”.

____________________________________________________

Employee Signature

____________________________________________________

Employee Address

____________________________________________________

Date ________________________________________________

07/1982

revised: 04/1995

01/1998

01/2002

01/2003

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Employee Accident/injury/illness Report Form - Cohoes City School District Page 3