Medical Excuse Form PDF Details

Doctor, I can't come in to work today. I have a fever and chills. My throat hurts and my chest feels tight. I don't think it would be wise for me to leave the house. If you've ever been ill enough that you couldn't go to work, you know how important it is to have a doctor's note excusing you from duty. For most people, a simple note will do the trick; but what if you're a federal employee or military member? In those cases, your supervisor will likely want something more official-looking than a handwritten note from your doctor.

The listing contains details about the medical excuse form. You'll have the likely time you may need to prepare the form as well as extra details.

QuestionAnswer
Form NameMedical Excuse Form
Form Length2 pages
Fillable?Yes
Fillable fields7
Avg. time to fill out1 min 58 sec
Other namesdoctors excuse for work from hospital, doctor excuse template, doctor excuse, dr excuse for work

Form Preview Example

REQUEST FOR EXCUSE FROM JURY DUTY - MEDICAL

FOR JUROR/PROSPECTIVE JUROR:__________________________________________________

(Required)

9-DIGIT BAR CODE PARTICIPANT NUMBER:_________________________________________

(Required)

This request is for a permanent excuse from a QUALIFICATION QUESTIONNAIRE:______________

This request is in response to a SUMMONS, date when your service begins: ____________________

Check the category closest to what your request is based on:

[

] Health or Medical (see section titled Medical Excuse Request below)

[

] Other (Explain in the medical statement section or in a separate letter)

MEDICAL EXCUSE REQUEST

Your medical provider should explain your medical condition using this form or in a letter. The statement must include WHY you need to be excused, the DAYS/DATES you need to be excused and WHEN YOU MAY BE ABLE TO SERVE in the future.

Please do not ask court staff to contact your medical provider. It is the juror=s responsibility to provide the required documentation. Any request that cannot be easily read will automatically be denied.

Attention Medical Provider. Using the medical statement section of this form or in a separate letter, please briefly state the health or medical condition(s) the patient listed at the top of this form has that you feel will prevent he or she from serving as a federal juror. You do not have to provide personal information on the specific medical condition. If the individual is gainfully employed outside their residence, please indicate why serving on a jury would be more difficult than the requirements of their employment. If the medical condition is temporary, please indicate such, as well as when he or she will be able to serve in the future. If the medical or health condition is chronic and the individual should be permanently excused, please indicate this. The information you provide must be based on your knowledge of this individual=s health and medical condition. Do not indicate that the patient merely feels he or she should be excused as this is incomplete information which will automatically invalidate the request and the request will be considered denied. Please print and sign your name and the name of the medical office you are affiliated with. Thank you.

Please do not ask court staff to contact your medical provider. It is the juror=s responsibility to obtain the required information.

Excuse requests cannot be accepted on the date you are scheduled to appear for jury duty. You should mail this form as soon as possible to: U.S. District Court, 324 W. Market St., Greensboro, NC 27401 Attn: Jury.

YOU MUST ALSO RETURN YOUR COMPLETED QUALIFICATION QUESTIONNAIRE OR THE

COMPLETED BOTTOM PORTION OF YOUR JURY SUMMONS

MEDICAL STATEMENT OF NEED FOR EXCUSE FROM JURY DUTY

FOR JUROR/PROSPECTIVE JUROR: _____________________________________________________

(Required)

9-DIGIT BAR CODE PARTICIPANT NUMBER: ____________________________________________

(Required)

_______________________________________________________________

_______________________________________________________________

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Signature of Medical Provider

Printed Name of Medical Office

Date

How to Edit Medical Excuse Form Online for Free

It won't be a challenge to create doctors excuse for work taking advantage of our PDF editor. This is how it is easy to rapidly create your file.

Step 1: The first thing should be to press the orange "Get Form Now" button.

Step 2: So, you may edit the doctors excuse for work. Our multifunctional toolbar helps you add, get rid of, customize, highlight, as well as carry out other sorts of commands to the content material and fields inside the form.

These areas are inside the PDF template you will be completing.

portion of empty spaces in dr excuse for work

Include the expected particulars in the FOR, JUROR, PROSPECTIVE, JUROR DIGIT, BARCODE, PARTICIPANT, NUMBER and Required, Required field.

Entering details in dr excuse for work stage 2

Note down the expected details as you are on the Signature, of, Medical, Provider Printed, Name, of, Medical, Office and Date area.

part 3 to filling out dr excuse for work

Step 3: Click "Done". Now you may export your PDF file.

Step 4: Just be sure to create as many duplicates of the document as possible to stay away from future troubles.

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