Tardy to Work or School

__________________________________________________ will be late to:

_____ Work

_____ School

__________________________________________________ was seen today and discharged from our facility at __________.

_____ He/she may return to work or school but must still avoid physical activity from now until: ____________________

_____ He/she may return to full physical activity as of: ____________________

Caregiver's signature: ________________________________________

Date: ______________________________________________________