Form HRS-114 "Medical Note - Summary Form" - Newfoundland and Labrador, Canada

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Download Form HRS-114 "Medical Note - Summary Form" - Newfoundland and Labrador, Canada

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Compensation and Benefits Division
Medical Note – Summary Form
(Employees in SSLA only)
Employee Section
Employee Full Name (printed): ___________________________________
Employee ID #: ________________________________________________
Department Name: ______________________________________________
Date Medical Note Provided to Approver: __________________________
Date(s) on Medical Note: _________________________________________
Notes:
1. Your employee ID #
can be found on your cheque stub (9 digit number).
2. Keep a copy of your note for your records.
3. Attach your medical documentation to this form.
4. Give completed form & medical note to your Approver.
Approver Section
Required Action for Compensation & Benefits:
File only
Update leave request to “sick leave – certified” for dates indicated on note & file
Approver/Manager Signature: _________________________________
Note:
1. Forward completed form with medical note to the Compensation & Benefits Service Center via
Email:
CompensationBenefits@gov.nl.ca
(use subject line: Medical Note & Summary Form)
or Mail:
Compensation & Benefits Division
Human Resource Secretariat
Main Floor, West Block
P.O. Box 8700
St. John’s, NL A1B 4J6
2. The approver is responsible for ensuring that forms are sent to the correct email or mailing address
Under the authority of the Financial Administration Act, personal information will be collected for the purpose of processing your sick leave request(s).
Your personal information is protected by the Access to Information and Protection of Privacy Act and will not be disclosed without consent or
authorization. Any questions or comments can be directed to the Compensation and Benefits Service Centre Specialists at 729-7690, 1-888-729-7690 or
CompensationBenefits@gov.nl.ca.
Issue Date: June 2016
HRS-114
Compensation and Benefits Division
Medical Note – Summary Form
(Employees in SSLA only)
Employee Section
Employee Full Name (printed): ___________________________________
Employee ID #: ________________________________________________
Department Name: ______________________________________________
Date Medical Note Provided to Approver: __________________________
Date(s) on Medical Note: _________________________________________
Notes:
1. Your employee ID #
can be found on your cheque stub (9 digit number).
2. Keep a copy of your note for your records.
3. Attach your medical documentation to this form.
4. Give completed form & medical note to your Approver.
Approver Section
Required Action for Compensation & Benefits:
File only
Update leave request to “sick leave – certified” for dates indicated on note & file
Approver/Manager Signature: _________________________________
Note:
1. Forward completed form with medical note to the Compensation & Benefits Service Center via
Email:
CompensationBenefits@gov.nl.ca
(use subject line: Medical Note & Summary Form)
or Mail:
Compensation & Benefits Division
Human Resource Secretariat
Main Floor, West Block
P.O. Box 8700
St. John’s, NL A1B 4J6
2. The approver is responsible for ensuring that forms are sent to the correct email or mailing address
Under the authority of the Financial Administration Act, personal information will be collected for the purpose of processing your sick leave request(s).
Your personal information is protected by the Access to Information and Protection of Privacy Act and will not be disclosed without consent or
authorization. Any questions or comments can be directed to the Compensation and Benefits Service Centre Specialists at 729-7690, 1-888-729-7690 or
CompensationBenefits@gov.nl.ca.
Issue Date: June 2016
HRS-114