West Springfield Education Association
                   SICK BANK MEDICAL FORM Unit D
                      Submit to your physician

_______________________________ is a patient under medical care by our office.
Patient's Name

He/She must discontinue working as of __________________________ 20___

and will need to remain out of work through ______________________ 20___    due to a serious illness.

This patient will return to work as of __________________________ 20___

Please state the nature of the serious illness of your patient. (Article 12 #4 of the current WSEA Unit D contact)  ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

___________________________        _____________________________
Physician's Name                                        Physician's Signature


________________________________________________________________________________________________________________________________
Physician's Office Address: Street, City, State and Zip Code



_____________________________________________________________________
Office Phone Number                                                            Date

Please return to:
West Springfield Education Association
Sick Bank Committee
P.O. Box 566
West Springfield, MA 01090

or

West Springfield Middle School
31 Middle School Drive
West Springfield, MA 01089

C/O Laurie Ashe

10/8/2017