ࡱ> OQN bjbjWW .H55T(((((<<<8t<.TT"vvvQQQ$g,(QQ,((vvANNN(v(vNNNNvsESFNW0N b N (NQvTND_;QQQ,,dQQQ QQQQQQQQQ : Classified Staff Union at the ý SICK LEAVE BANK APPLICATION SECTION ONE (To Be Completed By Member) Name: Employee ID Number: Home Address:  Home Telephone Number: Alternate Telephone Number: Department: Job Title: Supervisor/Department Head: Last Day of Work: Expected Date of Return to Work: Nature of Illness or Injury: Please include information in support of your request. Outline specifically the time frame you request. Signature: Date:  Classified Staff Union at the ý SICK LEAVE BANK APPLICATION SECTION 2 (To Be Completed by Physician) Name of Patient: Patients condition and date of onset:  How long have you been treating this patient for this condition; include dates of first and most recent visits:  Please describe your treatment plan and prognosis for this patient:  Please provide a date when you believe this patient will be able to return to work: Would you anticipate the patient will be able to return to work prior to this date on a modified work schedule? If yes, please specify the date of return to work and the length of a modified work schedule.  I hereby certify that I have examined the above named patient and certify under the pains and penalties of perjury that the information listed is true, based upon my knowledge and belief. Signature of Physician: ______________________________________ Date: ____________  Please print the following information: Name of Physician: ____________________________________________________ Address: ____________________________________________________ Telephone Number: ____________________________________________________ Specialty: ____________________________________________________ Registration Number: ____________________________________________________      PAGE  PAGE 1 Drafted January 2007. 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