Form Ssl - Application For Supplemental Sick Leave (Page 3 of 6) in pdf

Form Ssl - Application For Supplemental Sick Leave Page 3

STATE OF NH

APPLICATION FOR SUPPLEMENTAL SICK LEAVE

Part II - to be completed by the employee’s physician or medical practitioner.

Important: Forms which are incomplete may result in denial of the

employee’s application for Supplemental Sick Leave.

The employee named in PART I has applied to receive supplemental sick leave through the

Supplemental Sick Leave Program established by the State of NH. You are requested to complete

the information below for this individual patient.

PLEASE PRINT OR TYPE– ALL FIELDS MUST BE COMPLETED

1. Patient’s Name/Address:

2. Most recent date of examination:

3. The patient is/was:



Under my professional care

From:

To:



Hospitalized (N/A if not

From:

To:

applicable.)

4. Is the patient’s health condition work-related?



Yes



(If yes, please explain.)

5. The patient has been incapacitated from performing



Yes



his/her duties:

From:

To:

6. Anticipated duration the patient will be unable to work

due to the condition:

From:

To:

7. Will the patient need to attend follow-up treatment



Yes

appointments?

From:

To:

8. If the patient is not able to return to full duty employment,



Yes



can the patient return to work at less than full duty?

(a) If yes, period of partial incapacity:

From:

To:

(b) Restriction(s) if any: ___________________________________________________________

________________________________________________________________________________

SSL V3

Rev 8/4/2014

Form Ssl - Application For Supplemental Sick Leave Page 3

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