Excuse from Work or School
Name_____________________________ needs to be excused from
work/school/physical education for the following dates:
___________________________________________________________.
He/she may return to work/school but must still avoid physical activity
as of this date:__________________________________.
He/she may return to full physical activity as of this date:
_______________________.
Additional comments/instructions:
Printed name: _________________________________
____________________________________________________________
Signature Title Date
Published by
RelayHealth.
Last modified: 2006-11-27
Last reviewed: 2006-09-01
This content is reviewed periodically and is subject to
change as new health information becomes available. The
information is intended to inform and educate and is not a
replacement for medical evaluation, advice, diagnosis or
treatment by a healthcare professional.
© 2009 RelayHealth and/or its affiliates. All Rights Reserved.
