Employees Notification Form Page 2
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2CERTIFICATION BY EMPLOYER
START OF CONFINEMENT (Exact Date)
SICKNESS NOTIFICATION WAS RECEIVED BY US ON
SICKNESS OCCURRED WHILE (working, on leave, etc)
______________
19 ______ thru: Mail/ Phone
COMPANY HAS NO WAY OF VERIFYING THE SICKNESS BECAUSE: (Check applicable box)
The place of confinement was in
Company has no physician
He/she notified us only upon returning to work on
_______________________________
which is ____________ kms away.
NATURE OF BUSINESS
NO. OF EMPLOYEES
COMPANY ID NUMBER
PRINTED NAME OF SIGNATURE OF COMPANY EXECUTIVE
EMPLOYED
FOR SSS USE ONLY
MEDICAL EVALUATION
FINAL DIAGNOSIS
APPROVED: ____________________ days, from ____________________ to _____________________
REDUCED: ____________________ days, from ____________________ to _____________________
DENIED: ______________________ days, from ____________________ to _____________________
CLAIMANT TO COME FOR PHYSICAL EXAMINATION/CHEST X-ray
Submit: ____________________________________
Returned: _______________________________________
PREVIOUSLY APPROVED CONFINEMENT PERIOD: From ___________________________ to _____________________________
(Exact Date)
(No. of Days)
SIGNATURE OF SSS MEDICAL EXAMINER/ RETAINER PHYSICIAN
DATE EVALUATED
RECONSIDERATION/ EXTENSION:
No. of Days
FROM
TO
MEDICAL EXAMINER
DATE
IMPORTANT INSTRUCTIONS
1. The employee shall notify his employer of his sickness or injury within five (5) calendar days after the start of his confinement. Within five (5) days from receipt of
notice or knowledge of the sickness or injury, the employer shall record in his logbook the facts thereof and within five (5) days thereafter the employer shall notify the
Medical Evaluation Section of the nearest SSS branch or Representative Office. However, in cases where the sickness or injury sustained by the employee while working or
within the premises of the employer, the employee shall be deemed to have notified his employer. The foregoing prescription period of NOTIFICATION does not apply to
HOSPITAL confinement.
2. This form, after having been properly accomplished, shall be submitted in two (2) copies to the Employer by the sick employee or his representative. The employer
shall submit the ORIGINAL to the Medical Evaluation Section of the SSS branch or Representative Office within the prescribed period in instruction No. 1.
3. Use this form for the purposes of an INITIAL SICKNESS NOTIFICATION and INTERMEDIATE or FINAL SICKNESS NOTIFICATION, with the Attending Physician
checking the proper box in the PART II, (Medical Certificate Portion) of this form.
4. For the items "CLINICAL SUMMARY" and " PROLONGED CONFINEMENT DUE TO" in PART II of the form, symptoms, physical findings, laboratory examinations
and reports; X-ray plates; special diagnostic procedures. If any, must be submitted with this form. In cases of prolonged confinement, a progress report of the patient, in
addition to those already stated, must be submitted. If spaces provided are not enough, attach an additional sheet herewith.
5. In cases of prolonged confinement or sickness of the employee that will extend beyond the initial estimate, on a previous estimated period, this form will be
accomplished again by the employee and his Attending Physician, and submitted to the SSS within five (5) days requirement, after the previous estimate, and the Attending
Physician will check the applicable boxes in PART II thereof.
6. For further details, refer to EC Circular No. 2-1 re: Sickness Notification requirement and procedures.
7. Physical examination will be held only in the morning from 8:00 to 12:00, Monday thru Friday. Those who cannot come should notify the SSS, Medical Evaluation
Section of the SSS branch or Representative Office immediately.
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