Form Ssl - Application For Supplemental Sick Leave (Page 4 of 6) in pdf

Form Ssl - Application For Supplemental Sick Leave Page 4

STATE OF NH

APPLICATION FOR SUPPLEMENTAL SICK LEAVE

9. Describe in detail: the nature, date injury or illness commenced, diagnosis, and treatment plan of the

illness, injury, impairment or physical or mental condition (please attach documentation if necessary):

a) Nature of injury/illness: _________________________________________________________

____________________________________________________________________________

b) Date condition commenced: ____________________________________________________

c) Diagnosis: __________________________________________________________________

d) Treatment Plan: _____________________________________________________________

___________________________________________________________________________

e) Prognosis: _________________________________________________________________

___________________________________________________________________________

10. PHYSICIAN’S OR PRACTITIONER’S SIGNATURE

Name: ___________________________________

Title: ___________________________

(Please Print)

__________________________________

Date: __________________________

(Signature)

Address: _____________________________________ Phone: _________________________

SSL V3

Rev 8/4/2014

Form Ssl - Application For Supplemental Sick Leave Page 4