Menerangkan bahwa :
Nama : ...............................................................................
Umur : ...............................................................................
Jenis Kelamin : ...............................................................................
Pekerjan : ...............................................................................
Alamat : ................................................................................
Perlu istirahat karena sakit, selama .............. ( .................... ) hari terhitung mulai
tanggal ..........................................s/d........................................
Demikian, untuk yang berkepentingan agar maklum.
.......................................................
Pemeriksa,