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FORM I BROCKTON PUBLIC SCHOOLS PLEASE HAVE PHYSICIAN COMPLETE AT BEGINNING OF DISABILITY CERTIFICATION OF TEMPORARY DISABILITY OF 10 WORKING DAYS OR MORE. Please Print EMPLOYEE NAMEHOME PHONE POSITIONSCHOOL THE FORM SHOULD BE COMPLETED BY THE ATTENDING PHYSCIAN AT THE BEGINNING OF THE DISABILITY AND RETURNED TO THE HUMAN RESOURCES OFFICE. 43 Crescent St. Brockton MA 02301 or fax 508-580-7091 I do hereby certify as follows Name of Attending Physician 1. That I examined on the following dates...
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