Report of injury or illness return to work slip location employee name address ss# job title description of incident: state dept dob city phone date & time of incident state zip married yes no hire date gender male female employee signature:...
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Return to work release form: the university of texas at austin to be completed by the employee name: ut eid #: shift: department: work phone: home phone: supervisor: i understand that if my release includes workplace restrictions related to my...
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The university of toledo -college of medicine excused absence pre-clinical years request form name: class year: address: city: state: zip: telephone: pager: beginning date: ending date: courses missed: reason for request: attach appropriate...
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P.o. box 7339 austin, texas 78713-7339 512-471-4955 healthyhorns.utexas.edu dear faculty member: university health services (uhs) clinicians do not routinely provide written excuses for students who miss classes or assignments due to short-term...
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Date. reasons. a. personal sickness. b. family sickness. c. bereavement ( please indicate relation). d. attendance in court (provide a copy of the notice to
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For internal purposes account number: medical record number: health system authorization for the release of protected health information social security number (last 4 digits only): patient name: previous name, if applicable: address: city: date...
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