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University of Toledo/PSA Leave Recipient Application ? Attachment Certification of Health Care Provider (Please Print) Employee's Name: (Last, First, Middle) UT Claim # Section IV, B of the University

This requirement applies to all PSA-covered conditions. Eligibility Status: Active Employee, Retired or Inactive Employee, Appointee, or Graduate Student. Proof of loss or reduction or change in work assignment is required. The following documents are required by employers to prove an employee's medical condition are required and may be provided by the employee or submitted as a substitute: Medical Letter from a licensed physician describing illness or injury and requesting leave to avoid significant loss or significant reduction in services or activities; Copies of bills or statements of income from current work, or a medical and dental statement showing a reduction in the employee's health. A copy of the employee's recent W2 as presented with the statement of service from the previous employer, with the physician's certification from the previous employer's medical provider; and, or for an employee, letter from one physician or medical specialist providing the certification of illness or injury and requesting leave for an illness or injury, with copies to be submitted with the statement of service. Application for leave must be accompanied by, or include the following: The names of the employee and an individual designated to speak for the employee; A copy of the Employee's recent W2 or other proof that the employee was employed during the most recent calendar year from the PSA Sick Leave Bank. The employer must make a cash payment of two dollars (2) to the PSA Sick Leave Bank to cover the two-dollar minimum payment for a PSA sick leave application, and a cash payment of 15% of an employee's gross annual compensation for a PSA sick leaves bank beneficiary. A maximum of six sick days may be used per year. Benefits Paid out: One-half of the two dollars minimum and 15% of employee's gross annual compensation (excluding medical, disability and other benefits paid to the employee). Sick days accrued: May be used in any portion of the calendar year. Eligibility Status: Active Employee, Retired, Retired Employee, Appointee, or Graduate Student. Proof of loss or reduction or change in work assignment is required. Application for leave must be accompanied by, or include the following: Employee's PSA Notice letter indicating the condition was listed as a qualifying medical condition which requires leave from the PSA Sick Leave Bank; Copies of bills or statements of income from current work, or a medical and dental statement showing a reduction in the employee's health, from your current employer.

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