Translation of temporary disability certificate

Medical documentation

Form # 095-У

STAMP

Ministry of health of Ukraine

Outpatients’ clinic

Central regional hospital

Certificate # 1

Of temporary disability of a student or of illness, quarantine and other reasons of a child’s absence in school or preschool educational establishment.

Outpatients’ clinic of Ostroh

Date of issue: —-

Name of educational establishment: —.

First name, last name, patronymic: —

Year of birth: —

Diagnosis: acute respiratory disease

Contact with infected patients (yes, no, which exactly): ___

Complicated by bronchitis

From – till —

From – till –

Round seal of Outpatients’ clinic

Round seal of a doctor

Signature

Head of Central regional hospital Signature