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• • <br /> ALAMEDA COUNTY <br /> STATEMENT TO SUPPORT REQUEST FOR SICK LEAVE <br /> INSTRUCTIONS: It is the employee's responsibility to have a physician certified to practice in <br /> California complete the form below in full, answering each question based upon his professional <br /> knowledge of the health situation for which sick leave Is requested. <br /> was under my professional care from <br /> Name of Employee <br /> • <br /> • <br /> to • . The patient was seen by me for the <br /> • Date Date - <br /> following conditions or disorder: <br /> My diagnosis of the patient's condition is: <br /> This diagnosis is based upon (check applicable statement(s)): <br /> symptoms confirmed by observation or test <br /> symptoms reported by the patient <br /> I am aware that the employee's work duties are as follows (to be filled in by the employee, describing . <br /> the specific job that the person performs for the County of Alameda): <br /> Based upon my understanding of the employee's Job assignment and my assessment of the <br /> employee's health situation, it is my recommendation that the person return to work on <br /> Date <br /> I declare under penalty of perjury that to the best of my knowledge and belief the foregoing is true and <br /> correct. Executed at , California, this , of <br /> 19 <br /> Signature of Physician <br /> 217 <br /> FIRE - 51 <br /> • <br /> • <br />