[PDF] FORM 1-A MEDICAL CERTIFICATE - V A H A N

FORM 1-A MEDICAL CERTIFICATE - V A H A N

FORM 1-A [See Rules 5(1), (3), (7), 10(a), 14(d) and 18(d)] MEDICAL CERTIFICATE Space for passport size photograph [To be filled in by a registered medical practitioner appointed for the purpose by the State Government or person

Medical Certificate - Bupa

Medical Certificate 1 Before completing this certificate, see the back page for important information about pre-existing medical conditions 2 Please complete all details that are relevant to you, read the declaration and sign all the relevant signature panels 3

Medical Certificate Note - Travel Guard

Medical Certificate Note: • Please provide contact information for all Physicians or any Provider of Medical Services that the person having the Sickness or Injury had seen 180 days prior to the purchase of this insurance policy through the Scheduled Departure Date • All information is treated as private and confidential Provider #1

MEDICAL CERTIFICATE FOR EMPLOYMENT INSURANCE SICKNESS BENEFITS

Name of Medical Doctor (Print)SpecialityArea Code Telephone NumberAddressSignature of Medical Doctor Date SC INS5140 (2017-01-005) E GIVE THE COMPLETED FORM TO THE PATIENT DISPONIBLE EN FRANÇAIS - INS 5140 F Date on which the above patient became unable to work due to their medical condition

APPLICATION FOR MEDICAL CERTIFICATE (FORM CG-719K

a medical certificate that satisfies the Maritime Labor Convention (MLC), AND want to be qualified for lookout duties should submit this form Sections III (Medical Conditions), IV (Medications) and V (Physical Examination) of the CG 719K DO NOT have to be completed The medical certificate will be restricted to entry-level only 3

Air Canada, Medical Certificate, Form ACF5002-2-UA (2020-11)

Medical Certificate Return to: Agency Name: Attn: Human

No sick leave, federal FMLA, state family/medical leave (C G S 5-248a), special leave with pay in excess of five (5) days, or leave as otherwise prescribed by contract, shall be granted state employees unless supported by a medical certificate filed with, and acceptable to, the appointing authority The period of incapacity

MEDICAL CERTIFICATE GUARDIANSHIP OR CONSERVATORSHIP

MPC 400 (11/1/10) CRMDSEGThe individual's risk of harm to self or others is:C The likelihood of harm is:D RECOMMENDATIONS FOR LEVEL OF CARE/SUPERVISION NEEDED, INCLUDING HOUSING6 An institutional placement being pursued at the following:A If none, skip to section 7; if yes, answer:The individual requires the following level of supervision:B Less restrictive placement options have been pursued

CERTIFICATE OF MEDICAL FITNESS

Marine Order 76 (Health—medical fitness) 2017 requires that a Medical inspector have regard to the Standards for the medical examination of seafarers and coastal pilots and the relevant job task analyses contained within The assessment of medical fitness for service at sea is a matter for the Medical inspector’s professional judgement