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Physical Education Short-term Illness or Injury Restriction Report

About this Form

Form number: 345-22

Audience:  Parents/Guardians, Attending Physician, Principals

Last revised: June 2019


This form should be considered for completion if an authorized health care provider has indicated that a student’s physical activity should be restricted in physical education classes. The authorized health care provider may use this form to specify the nature and duration of the restriction.

Adobe PDF Physical Education Short-term Illness or Injury Restriction Report834 KEnglish
Adobe PDF Reporte de Restricción de Educación Física a Corto Plazo Debido a Enfermedad o Lesión425 KSpanish
Adobe PDF Rapport de restriction d'activités en cours d'éducation physique due à une maladie bénigne ou une blessure425 KFrench
Adobe PDF Báo Cáo Hạn Chế Sinh Hoạ t Thể Thao do Bệnh Tật hoặc Chấn Thương Ngắn Hạn480 KVietnamese
Adobe PDF 體育課短期疾病或受傷限制報告514 KChinese
Adobe PDF 질병 또는 상해에 의한 체육 단기 제한 보고 양식460 KKorean
Adobe PDF የሰውነት ማጎልመሻ ትምህርት ለአጭር ጊዜ ህመም ወይም የአካል ጉዳት የመታገድ-የመገደብ ሪፖርት455 KAmharic

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