Form HRD-001 "Physicians' Certification Form - State of Mississippi Donated Leave Program" - Mississippi

What Is Form HRD-001?

This is a legal form that was released by the Mississippi Department of Education - a government authority operating within Mississippi. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2010;
  • The latest edition provided by the Mississippi Department of Education;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form HRD-001 by clicking the link below or browse more documents and templates provided by the Mississippi Department of Education.

ADVERTISEMENT
ADVERTISEMENT

Download Form HRD-001 "Physicians' Certification Form - State of Mississippi Donated Leave Program" - Mississippi

1398 times
Rate (4.8 / 5) 70 votes
State of Mississippi Donated Leave Program
Mississippi Department of Education
PHYSICIANS' CERTIFICATION FORM
Part
A.
To Be Completed by the Employee
Employee Name/Print
SSN
Phone#
Department
Address
City,
State
Zip Code
Part B. To Be Completed by the Physician
Definition:
Catastrophic injury or illness means a life-threatening injury or illness of an employee or a member
of an employee's immediate family, including only a spouse, parent, step-parent, sibling, child or stepchild, which
totally incapacitates the employee from work, as verified by a licensed physician, and forces the employee to
exhaust all leave time earned by that employee, resulting in the loss of compensation for the employee. Conditions
that are short-term in nature, including, but not limited to, common illnesses such as influenza and the measles,
and common injuries are not catastrophic.
Chronic illnesses or injuries, such as cancer or major surgery, which
result in intermittent absences from work and which are long-term in nature and require long recuperation
periods, may be considered
catastrophic.
1. In your opinion does the employee meet the "Catastrophic injury or illness" definition as
described above?
Yes
No
If yes, please describe in detail, diagnosis
description and if applicable, method of treatment and probable duration of condition. (Attach
additional sheet if more space is needed)
2.
Date patient was first diagnosed with catastrophic injury or
illness:
3.
Has the patient been hospital confined?
Yes
No
If yes, provide hospital name and
admittance date:
4. Anticipated date that employee will be able to return to work?
Physician's Name:
(Please Print)
Specialization
Address:
_
Date:
Physician's Signature:
{Please do not use stamp or Designee Signature)
HRD-001 New 08/2010
State of Mississippi Donated Leave Program
Mississippi Department of Education
PHYSICIANS' CERTIFICATION FORM
Part
A.
To Be Completed by the Employee
Employee Name/Print
SSN
Phone#
Department
Address
City,
State
Zip Code
Part B. To Be Completed by the Physician
Definition:
Catastrophic injury or illness means a life-threatening injury or illness of an employee or a member
of an employee's immediate family, including only a spouse, parent, step-parent, sibling, child or stepchild, which
totally incapacitates the employee from work, as verified by a licensed physician, and forces the employee to
exhaust all leave time earned by that employee, resulting in the loss of compensation for the employee. Conditions
that are short-term in nature, including, but not limited to, common illnesses such as influenza and the measles,
and common injuries are not catastrophic.
Chronic illnesses or injuries, such as cancer or major surgery, which
result in intermittent absences from work and which are long-term in nature and require long recuperation
periods, may be considered
catastrophic.
1. In your opinion does the employee meet the "Catastrophic injury or illness" definition as
described above?
Yes
No
If yes, please describe in detail, diagnosis
description and if applicable, method of treatment and probable duration of condition. (Attach
additional sheet if more space is needed)
2.
Date patient was first diagnosed with catastrophic injury or
illness:
3.
Has the patient been hospital confined?
Yes
No
If yes, provide hospital name and
admittance date:
4. Anticipated date that employee will be able to return to work?
Physician's Name:
(Please Print)
Specialization
Address:
_
Date:
Physician's Signature:
{Please do not use stamp or Designee Signature)
HRD-001 New 08/2010
Part C.
To Be Completed by the Employee or Person acting on behalf of the Employee
I understand that the information requested on this Physician's Certification of Catastrophic Injury or
Illness Form is for the use of determining my eligibility to participate in the State of Mississippi
Donated Leave program.
Failure to provide all of the
requested information
will result in my request
not being processed or approved.
Further, I am aware that any medical information provided will
remain confidential and will not be shared with other employees in the Office of Human Resources,
my Department or elsewhere within the Department of Education. If I am acting on behalf of the
employee patient, I am providing documentation as having Power of Attorney, which is attached to this
form.
Employee/Patient Signature
Date
Print Name of Person acting on behalf of Employee/Patient
Date
Signature of Person acting on behalf of Employee/Patient
Date
HRD-001New 08/2010
Page of 2