Form Ssl - Application For Supplemental Sick Leave (Page 2 of 6) in pdf

Form Ssl - Application For Supplemental Sick Leave Page 2

STATE OF NH

APPLICATION FOR SUPPLEMENTAL SICK LEAVE

Part I – Continued

13. Are there extenuating circumstances as to why you are out of paid leave (paid leave includes sick leave,

annual leave, floating holidays, bonus days, and compensatory time)? Please describe:

PLEASE NOTE: Your physician or medical provider must complete Part II of this application and the

stated diagnosis, treatment plan and prognosis provided must support this application. The physician

or medical practitioner must provide all of the information requested on Part II of this form and he/she

must sign and date the form.

In requesting supplemental sick leave, I agree to have my physician/medical practitioner provide the

information requested in Part II of the application.

14. Signature: ___________________________________Date: __________________________________

15. Completed by:



Employee

Designee (specify):

_____________________________________

16. TO BE COMPLETED ONLY BY THE EMPLOYEE. In applying for supplemental sick leave, I hereby

authorize the use and disclosure of my individually identifiable health information as follows: my name, the

agency I work for, the reason for my request, my last day of work, the date my leave available for this absence

was or will be exhausted, and the expected duration of my absence. I understand that I may revoke this

authorization by notifying the department in writing. However, the revocation will not be valid if the department

has taken action in reliance on this authorization. I further understand that the information I have authorized

for disclosure may be re-disclosed and no longer protected by federal privacy regulations.

Signature: ___________________________________

Date: ______________________________

SSL V3

Rev 8/4/2014

Form Ssl - Application For Supplemental Sick Leave Page 2