Get the free Catastrophic Leave Medical Certification (PDF) - San Jose State ... - sjsu

CATASTROPHIC LEAVE MEDICAL CERTIFICATION HUMAN RESOURCES FORM Employee Support Services One Washington Square San Jose, CA 95192-0046 408-924-2250 408-924-1701 (fax) Instructions: Complete employee

How to fill out catastrophic leave medical certification

How to fill out catastrophic leave medical certification?

1. Obtain the catastrophic leave medical certification form from your employer or human resources department.
2. Provide your personal details, including your name, employee identification number, and contact information.
3. Fill in the date of your injury or illness that has caused you to be unable to work.
4. Provide a detailed description of your injury or illness, including symptoms, diagnosis, and any medical treatments received.
5. Include the name and contact information of your healthcare provider who has treated or is currently treating you.
6. Indicate the anticipated duration of your leave and when you expect to return to work.
7. Attach any relevant medical documents, such as medical records or doctor's notes, to support your certification.
8. Sign and date the form, certifying that the information provided is true and accurate to the best of your knowledge.
9. Submit the completed form to your employer or human resources department for review and processing.

Who needs catastrophic leave medical certification?

1. Employees who have experienced a severe injury or illness that has rendered them unable to work.
2. Individuals who require an extended period of time off work due to their injury or illness.
3. Those who wish to request catastrophic leave benefits from their employer.

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What is catastrophic leave medical certification?

Catastrophic leave medical certification is a document that certifies an employee's medical condition, allowing them to apply for catastrophic leave, which provides additional time off from work for their medical needs.

Who is required to file catastrophic leave medical certification?

Employees who need to take time off for medical reasons and wish to apply for catastrophic leave are required to file the corresponding medical certification.

How to fill out catastrophic leave medical certification?

To fill out catastrophic leave medical certification, an employee must provide their personal information, details about their medical condition, and any supporting documentation from healthcare professionals.

What is the purpose of catastrophic leave medical certification?

The purpose of catastrophic leave medical certification is to validate an employee's medical condition and establish their eligibility for catastrophic leave, which provides extended time off from work.

What information must be reported on catastrophic leave medical certification?

Catastrophic leave medical certification must report the employee's personal information, details about their medical condition, duration of leave requested, and any supporting medical documentation.