Employees Notification Form printable pdf download

Republic of the Philippines

SOCIAL SECURITY SYSTEM

EMPLOYEES NOTIFICATION

Form B‐300 (8/75)

IMPORTANT: PLEASE READ INSTRUCTIONS AT THE BACK BEFORE FILLING UP FORM

PART I CONFINED MEMBER'S NOTIFICATION (To be filled up by confined member)

NAME OF CONFINED MEMBER (Please Print in Full)

SS NUMBER

TAX ACCOUNT NUMBER

ADDRESS OF EMPLOYER

RESIDENCE OF CONFINED MEMBER

EMPLOYER'S REGISTERED NAME

EXACT DATE OF CONFINEMENT: PLACE/ ADDRESS OF CONFINEMENT

This is to notify my employer that I am currently confined. The name of employer, the place/address and the date when such confinement started are indicated above. I

certify that I am hereby waiving in favor of the SSS all information which my physician has acquired while attending to me as a patient in a professional capacity which

information was necessary to enable him to act in that capacity. I hereby consent to the examination of my physician as to all information acquire by him from physical/ mental

examination of any person and all results of X-ray, laboratory and/or special diagnostic examinations. I further waive all information held privilege by law.

NAME AND SIGNATURE OF MEMBER'S AUTHORIZED REPRESENTATIVE

SIGNATURE OF CONFINED MEMBER

(RIGHT THUMBMARK)

(If sick member cannot write, print right thumbmark)

(Please sign over your printed name)

PART II MEDICAL CERTIFICATE (This block to be filled by attending physician)

I CERTIFY THAT I HAVE EXAMINED/ATTENDED the above‐named employee and state the following:

EXACT DATE EXAMINED ATTENDED

AGE

SEX

CIVIL STATUS

OCCUPATION

ADDRESS OF CONFINEMENT

THIS IS BEING SUBMITTED AS: (Check applicable box and state corresponding report/ findings)

an INITIAL CERTIFICATE

an INTERMEDIATE

a FINAL CERTIFICATE

CLINICAL SUMMARY (Please read instruction #4 at the back)

PROLONGED CONFINEMENT DUE TO:

(a) FINAL DIAGNOSIS (Give progress report of patient)

DIAGNOSIS

IN MY MEDICAL OPINION the confinement including the convalescing

NO. OF DAYS CONFINEMENT EXTENSION EFFECTIVE (Exact Date)

or recuperation period may last for __________ days.

CONFINED AT

FIT TO RESUME WORK ON ____________________ (estimated date)

Confinement VERIFIED by employer/company physician

WILL BE FIT TO RESUME WORK ON (Exact Date)

Confinement NOT VERIFIED by employer/company physician

PRINTED NAME & SIGNATURE OF ATTENDING PHYSICIAN

PRINTED NAME & SIGNATURE OF EMPLOYER/ ATTENDING PHYSICIAN

ADDRESS OF PHYSICIAN

REGISTRATION/ LICENSE NO.

PART III EMPLOYER'S REPORT (This block to be filled up by Employer)

NAME OF CONFINED MEMBER

OCCUPATION (Exact description of work)

TIME OF WORK (Inclusive hours)

HOW LONG EMPLOYED?

Date of Employment

CAUSE OF INJURY

DESCRIBE FULLY HOW ACCIDENT HAPPENED AND STATE WHAT EMPLOYEE

a) Much less or Tool __________________________________________

WAS DOING WHEN INJURED.

b) Kind of Power (hand, foot, electrical steam, etc.)

c) Part of Machine on which accident occurred __________________

Time, date p ace o acciden :

d t & l

& l

id t

d) Was he injured during his regular occupation? ________________

EMPLOYER'S/ COMPANY'S ACKNOWLEDGEMENT RECEIPT

EMPLOYER'S ACKNOWLEDGEMENT RECEIPT

(FROM SSS)

(FROM COMPANY)

NAME OF CONFINED MEMBER

EMPLOYER

ADDRESS

EMPLOYER

CONFINEMENT PERIOD (Exact Date)

START OF CONFINEMENT (Exact Date)

FROM

RECEIVED BY

DATE RECEIVED

NOTIFICATION RECEIVED BY

DATE RECEIVED

Employees Notification Form

Related Articles

Related forms

Related Categories