Employee:
PLEASE COMPLETE THIS SECTION, SIGN AND HAVE YOUR PHYSICIAN COMPLETE IN DETAIL THE BACK OF THIS FORM AND RETURN TO OAKLAND UNIVERSITY, EMPLOYEE RELATIONS DEPARTMENT, 144 NORTH FOUNDATION HALL, ROCHESTER, MI 48309-4401.
Name: _________________________________________ Date: ____________________
(Please Print)
Address: ______________________________________________________________ Telephone: ________________
(Street) (City) (Zip Code)
Department: __________________________ Supervisor: _____________________ Telephone: ________________
If absence is the result of an illness, give nature of disability and date you first noticed symptoms.
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If your disability is the result of an accident, please give date, time, place, and nature of accident.
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Date first consulted physician in
connection with this disability
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Date disability began
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Last work day
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When will you be able to resume work?
Name and address of physician consulted
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Have you been able to do any work since that date? YES ___ NO ___
If yes, please explain: ____________________
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I hereby declare that the answers given by me in this sick bank disability grant application are complete and true to the
best of my knowledge. I also authorize the release of all medical information that is related to my condition.
Employee Signature: __________________________________________ Date: _____________________
Physician00 StatementIN ORDER FOR AN APPROPRIATE EVALUATION TO BE MADE CONCERNING THE ELIGIBILITY FOR SICK BANK BENEFITS EACH QUESTION MUST BE ANSWERED IN DETAIL. PLEASE PRINT OR TYPE AND DO NOT ABBREVIATE. FAILURE TO DOCUMENT SPECIFICALLY WHY THE PERSON IS DISABLED MAY RESULT IN THE LOSS OF PAY.
Name of patient: ___________________________________________
Date symptoms first appeared or accident occurred: _______________
Date patient first consulted you for treatment of condition described below: __________________
Diagnosis: ________________________________________________________________________________________
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Is condition incidental to pregnancy? _________________________
If surgery is performed, give type of surgery and date(s) of surgery: ___________________________________________
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If patient is not totally disabled, what restrictions or temporary accommodations can be made in order to return your patient to work? (i.e.: shorter workweek, limitation of job functions performed, etc.) ___________________________________
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Patient is totally disabled from returning to work, even with restrictions: YES ___ NO ___
If yes, please state specific medical reason(s): ___________________________________________________________
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Expected date of return to work: ________ ________ ________
Month Date Year
Please print physician00 name: ____________________________________________
Physician00 Signature: ___________________________________________________ Date: ____________________
Address: __________________________________________ Telephone Number: ______________________
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