(pieczątka szkoły/placówki)
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Miejscowość, data
NOTATKA SŁUŻBOWA
Nauczyciel, funkcja: .........................................................................................................................................................................................
Data zdarzenia: ................................................................................................................................................................................................
Osoby uczestniczące w zdarzeniu:
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Krótki opis sytuacji (zdarzenia):
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Wnioski, ustalenia:
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Działania, kroki podjęte przez nauczyciela:
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(data i podpis)