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Get HI DOE OHR 300-001 2011-2024

_____________ Date: _______________________ MM/DD/YYYY Name of Licensed Physician (Print): __________________________________ Type of Practice: ___________________________ Address: __________________________________________________________ Tel#: ____________________________________ Distribution: Leave with Pay (Teachers): 1. Original - School; 2. Copy 1 - Employee; 3. Copy 2 - PRO (if leave exceeds one month) / Leave With Pay (EOs): 1. Original - School; 2. Copy 1 - Employee / Leave Without .

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