413E1 - Employee Physical Exam

CARROLL COMMUNITY SCHOOLDISTRICT

CARROLL, IOWA 51401-1911

 

Carroll Community School District Verification of Physical Examination

 

 

I have examined                                                                                               

                                      Please print name of person being examined

 

on                                          and found him/her to be

physically able to perform duties in the Carroll Community School District.

 

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Signature of Examining Doctor                                                      Date

 

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Printed Name of Examining Doctor