THE CITY UNIVERSITY OF NEW YORK
KINGSBOROUGH COMMUNITY COLLEGE
MEDICAL NOTE
(To be completed by attending physician)
EMPLOYEE’S NAME:________________________________________ SS#_______________________
ADDRESS:__________________________________________________TITLE:____________________
(NUMBER & STREET)
____________________________________________________________DEPT:____________________
(CITY STATE ZIP)
DATES OF DATE OF FIRST
ILLNESS:______________/_______________ TREATMENT:________________
FROM
TO
DATE OF LAST
TREATMENT
: __ _________________
COMPLETE
DIAGNOSIS
:_____________________________________________________________________________________________
____________________________________________________________________________________________________________
POSITIVE PHYSICAL
FINDINGS
:______________________________________________________________________________________________
____________________________________________________________________________________________________________
MEDICATION
: (If able to work at College while continuing medication)
_____________/_______________ __________________________________________________
YES
NO
(If yes, name medication)
DATE MAY RETURN TO WORK AND (If not immediately, explain below for College
ASSUME FULL JOB RESPONSIBILITIES:____________ review and records):_____________________
________________________________________________________________________________________
________________________________________________________________________________________
_________________________________________ _______________________
Physician’s Signature
Date
_________________________________________ (___)_____________________
Print Name Telephone # (including area code)
__________________________________________________________________________________________________
Address Street & Number City State Zip
_______________________________________________________
New York State Registration Number
FOR COLLEGE REVIEW:
DATE POSTED TO RECORD: __________________
FM1-2 (6/02)
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