Form ADM4312 "Application for Disability Leave Benefits Employer Statement" - Ohio

What Is Form ADM4312?

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

Form Details:

  • Released on January 1, 2018;
  • The latest edition provided by the Ohio Department of Administrative Services;
  • 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 printable version of Form ADM4312 by clicking the link below or browse more documents and templates provided by the Ohio Department of Administrative Services.

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Download Form ADM4312 "Application for Disability Leave Benefits Employer Statement" - Ohio

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APPLICATION FOR DISABILITY LEAVE BENEFITS EMPLOYER STATEMENT
The employer shall within five (5) days of receipt of the claim forward the claim and the claim recommendation to
the Ohio Department of Administrative Services (DAS), Disability Services Unit, 30 E. Broad St, 27th Floor, Columbus,
Ohio 43215. The agency may email claims to DAS.Disability@das.ohio.gov. Fax number: 1-614-466-0831. Please notify
the Disability Unit when you learn of any unexpected return to work or other changes in the employee’s status.
Employee Name
State of Ohio User ID
Date of Birth
Agency
Payroll#
Job Title
CBU
Date Last Worked
Number of Hours Worked that Day
Date Disability Occurred
Date Application Received
Application received within 20 days of date last worked
Yes
No
If no, 20 day filing date:
Information for:
Initial Application
Extension
Reinstatement
Date employee actually returned to work:
_______________________
One (1) year continuous service immediately prior to disability?
Yes
No*
Employee full time?
Yes
No*
Part time?
Yes
No*
If yes, give number of hours worked in 12 months preceding disability?
_______________________
Approved medical leave or FMLA
Yes
No*
Surgery performed?
Yes*
No
If yes, date confirmed and contact name:
_______________________
Was the employee on administrative leave, childbirth/adoption or suspended?
Yes
No*
If yes, give dates:
_______________________
If suspension, give type:
_______________________
Did doctor or employee indicate claim is worked related?
Yes*
No
Did employee indicate working for wage/profit?
Yes*
No
Altered forms in any way?
Yes*
No
Forms signed by employee and doctor? If no, obtain signature.
Yes
No
Drug addiction or alcohol?
Yes*
No
Attempted suicide or self-inflicted?
Yes*
No
Allow employee to return to work on a part-time basis:
Yes
No*
If yes, part-time schedule: Hours ______ Days ______ Weeks ______
Yes
No
Allow employee to return to work in a Transitional Work Program:
If yes, temporary modifications that can be made: __________________________
__________________________________________________________________________
ADM4312 (rev 01/18)
page 1 of 2
APPLICATION FOR DISABILITY LEAVE BENEFITS EMPLOYER STATEMENT
The employer shall within five (5) days of receipt of the claim forward the claim and the claim recommendation to
the Ohio Department of Administrative Services (DAS), Disability Services Unit, 30 E. Broad St, 27th Floor, Columbus,
Ohio 43215. The agency may email claims to DAS.Disability@das.ohio.gov. Fax number: 1-614-466-0831. Please notify
the Disability Unit when you learn of any unexpected return to work or other changes in the employee’s status.
Employee Name
State of Ohio User ID
Date of Birth
Agency
Payroll#
Job Title
CBU
Date Last Worked
Number of Hours Worked that Day
Date Disability Occurred
Date Application Received
Application received within 20 days of date last worked
Yes
No
If no, 20 day filing date:
Information for:
Initial Application
Extension
Reinstatement
Date employee actually returned to work:
_______________________
One (1) year continuous service immediately prior to disability?
Yes
No*
Employee full time?
Yes
No*
Part time?
Yes
No*
If yes, give number of hours worked in 12 months preceding disability?
_______________________
Approved medical leave or FMLA
Yes
No*
Surgery performed?
Yes*
No
If yes, date confirmed and contact name:
_______________________
Was the employee on administrative leave, childbirth/adoption or suspended?
Yes
No*
If yes, give dates:
_______________________
If suspension, give type:
_______________________
Did doctor or employee indicate claim is worked related?
Yes*
No
Did employee indicate working for wage/profit?
Yes*
No
Altered forms in any way?
Yes*
No
Forms signed by employee and doctor? If no, obtain signature.
Yes
No
Drug addiction or alcohol?
Yes*
No
Attempted suicide or self-inflicted?
Yes*
No
Allow employee to return to work on a part-time basis:
Yes
No*
If yes, part-time schedule: Hours ______ Days ______ Weeks ______
Yes
No
Allow employee to return to work in a Transitional Work Program:
If yes, temporary modifications that can be made: __________________________
__________________________________________________________________________
ADM4312 (rev 01/18)
page 1 of 2
Employee Name
State of Ohio User ID
Date of Birth
Work-Related Claims:
Are you aware of other claims filed with BWC that may be related to this injury?
Yes
No
If yes, provide information pertaining to the BWC claim and/or injury ______________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Disciplinary Investigation:
Is the employee currently the subject of a disciplinary investigation?
Yes
No
If yes, provide answers to the following questions:
1. The date that the investigation was initiated _____________________________________________________________
2. The basis of the investigation: ___________________________________________________________________________
__________________________________________________________________________________________________________
3. Why access to the employee is necessary for completion of the investigation _______________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Agency Comments: ______________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Agency Recommendation:
Approval
Disapproval
Doctor review
Reasons for disapproval or doctor review: __________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Confirmation that employee’s PD is included
Yes
Agency Contact: __________________________________________________________________________________________
Phone #: __________________________________________ Fax #: ______________________________________________
Email Address: ___________________________________________________________________________________________
Appointing Authority or Designess Signature: ______________________________________________________________
Date: ____________________________________________________________________________________________________
ADM4312 (rev 01/18)
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