(School district Logo/Address)
CONSENT FORM
Physician Building
Dr. Anyone
Street
City, State Zip
Date: _____________
Patient Name: ______________________________________
Date of injury: ________
T.E.M.P. position: __________________________________
T.E.M.P. position is approved as is: Yes ______ No _______
T.E.M.P. position is approved with modifications below:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Disapproved for the following medical reasons:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Physician Signature: ________________________ Date: ______________
The injured employee's supervisor will read and understand the job requirements including
physical capacities. We agree to respect those limitations.
Supervisor Signature: ________________________ Date: ______________
