"Disability Supplemental Information Agency Coversheet" - Ohio

Disability Supplemental Information Agency Coversheet is a legal document that was released by the Ohio Department of Administrative Services - a government authority operating within Ohio.

Form Details:

  • Released on September 1, 2013;
  • The latest edition currently provided by the Ohio Department of Administrative Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Ohio Department of Administrative Services.

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Download "Disability Supplemental Information Agency Coversheet" - Ohio

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DISABILITY SUPPLEMENTAL INFORMATION
AGENCY COVERSHEET
Employee's Name:
State of Ohio User ID
Claim Number:
Agency:
Payroll #:
Information is for:
Return to work
Date employee ACTUALLY returned to work:
Extension
Reinstatement
NEW date last worked:
Part-time
Part-time schedule:
hours per day:
days per week:
Allow light/modified duty or Transitional Work Program (TWP)
yes
no
If yes, describe modifications that can be made or attach documentation of TWP agreement:
Approval
Disapproval
Dr. Review
Agency Recommendation:
(send PD)
Reason for disapproval or Dr. review:
Additional information or comments:
Agency contact:
Phone #:
E-mail:
Fax #:
Appointing Authority or Designee Signature
Date:
rev 09/13
DISABILITY SUPPLEMENTAL INFORMATION
AGENCY COVERSHEET
Employee's Name:
State of Ohio User ID
Claim Number:
Agency:
Payroll #:
Information is for:
Return to work
Date employee ACTUALLY returned to work:
Extension
Reinstatement
NEW date last worked:
Part-time
Part-time schedule:
hours per day:
days per week:
Allow light/modified duty or Transitional Work Program (TWP)
yes
no
If yes, describe modifications that can be made or attach documentation of TWP agreement:
Approval
Disapproval
Dr. Review
Agency Recommendation:
(send PD)
Reason for disapproval or Dr. review:
Additional information or comments:
Agency contact:
Phone #:
E-mail:
Fax #:
Appointing Authority or Designee Signature
Date:
rev 09/13