Request Absence for Personal Illness / Illness in Family - School District of Philadelphia

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NOTE: Top and bottom portions of this form must be filled out in their entirety and returned to Employee Health Services to insure continuation of salary.
REQUEST ABSENCE FOR
THE SCHOOL DISTRICT OF PHILADELPHIA
EMPLOYEE HEALTH SERVICES - SUITE 134
PERSONAL ILLNESS / ILLNESS IN FAMILY
440 N. BROAD STREET - PHILADELPHIA, PA 19130
A NEW CARD MUST BE SUBMITTED FOR EACH PAYROLL PERIOD --- NOT TO EXCEED 10 DAYS.
FAILURE TO SUBMIT CARDS MAY LEAD TO DISCIPLINARY ACTION.
EMPLOYEES ON LONG-TERM ILLNESS/ILLNESS IN FAMILY MAY NOT LEAVE THE CITY WITHOUT PRIOR APPROVAL FROM EMPLOYEE HEALTH SERVICES.
SECTION I - COMPLETED BY EMPLOYEE
Employee’s Last Name
First Name
M.I.
Employee ID
Date
Home Address
City
State
Zip Code
Home Phone
Work Location (School/Office)
Organization No.
Position Title
Number of Days Absent
From Date ( Month/Day/Year )
To Date ( Month/Day/Year )
Anticipated Date of Return
Signature of Employee
Signature of Principal/Administrator
Date
= = = THIS CARD DOES NOT REPLACE A MEDICAL REPORT FROM YOUR DOCTOR = = =
SEH-3 Part 1 (Rev. 11/11) Comm. Code 61602445418
SECTION II - AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION - ALL INFORMATION WILL BE KEPT CONFIDENTIAL
FOR EMPLOYEE ILLNESS
FOR ILLNESS IN THE FAMILY
I, the undersigned, authorize the release of all information regarding this
illness to the Office of Employee Health Services, for which I am requesting
personal illness absence.
Name of Employee: _________________________________________
Name of Family Member: ____________________________________
Name of Employee: ____________________________________________
Relationship to Employee:____________________________________
Employee I.D.: __________________________
Signature: _________________________________
Date:____________
SECTION III - COMPLETED BY EMPLOYEE’S PHYSICIAN OR FAMILY MEMBER’S PHYSICIAN
Name of Patient:_________________________________________________
Date of Last Visit: _________________________________
I certify that the above patient is / was under my professional care from (date) ____________________________ to ___________________________
The patient’s diagnosis/diagnoses: ____________________________________________________________________________________________
___ Disability From Pregnancy (EDD:___________________________ )
Other:___________________________________________________
= = = FORGERY OF PHYSICIAN’S SIGNATURE IS SUBJECT TO DISCIPLINARY ACTION = = =
Date employee may return to work
Physician’s Name:__________________________________________
Telephone:___________________
(Do not indicate indefinitely)
Address:_________________________________ City________________ State_____ Zip Code___________
____________________________
Signature:__________________________________________
Date: ______________________________
SEH-3 Part 2 (Rev. 11/11) Comm. Code 61602445418
NOTE: Top and bottom portions of this form must be filled out in their entirety and returned to Employee Health Services to insure continuation of salary.
REQUEST ABSENCE FOR
THE SCHOOL DISTRICT OF PHILADELPHIA
EMPLOYEE HEALTH SERVICES - SUITE 134
PERSONAL ILLNESS / ILLNESS IN FAMILY
440 N. BROAD STREET - PHILADELPHIA, PA 19130
A NEW CARD MUST BE SUBMITTED FOR EACH PAYROLL PERIOD --- NOT TO EXCEED 10 DAYS.
FAILURE TO SUBMIT CARDS MAY LEAD TO DISCIPLINARY ACTION.
EMPLOYEES ON LONG-TERM ILLNESS/ILLNESS IN FAMILY MAY NOT LEAVE THE CITY WITHOUT PRIOR APPROVAL FROM EMPLOYEE HEALTH SERVICES.
SECTION I - COMPLETED BY EMPLOYEE
Employee’s Last Name
First Name
M.I.
Employee ID
Date
Home Address
City
State
Zip Code
Home Phone
Work Location (School/Office)
Organization No.
Position Title
Number of Days Absent
From Date ( Month/Day/Year )
To Date ( Month/Day/Year )
Anticipated Date of Return
Signature of Employee
Signature of Principal/Administrator
Date
= = = THIS CARD DOES NOT REPLACE A MEDICAL REPORT FROM YOUR DOCTOR = = =
SEH-3 Part 1 (Rev. 11/11) Comm. Code 61602445418
SECTION II - AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION - ALL INFORMATION WILL BE KEPT CONFIDENTIAL
FOR EMPLOYEE ILLNESS
FOR ILLNESS IN THE FAMILY
I, the undersigned, authorize the release of all information regarding this
illness to the Office of Employee Health Services, for which I am requesting
personal illness absence.
Name of Employee: _________________________________________
Name of Family Member: ____________________________________
Name of Employee: ____________________________________________
Relationship to Employee:____________________________________
Employee I.D.: __________________________
Signature: _________________________________
Date:____________
SECTION III - COMPLETED BY EMPLOYEE’S PHYSICIAN OR FAMILY MEMBER’S PHYSICIAN
Name of Patient:_________________________________________________
Date of Last Visit: _________________________________
I certify that the above patient is / was under my professional care from (date) ____________________________ to ___________________________
The patient’s diagnosis/diagnoses: ____________________________________________________________________________________________
___ Disability From Pregnancy (EDD:___________________________ )
Other:___________________________________________________
= = = FORGERY OF PHYSICIAN’S SIGNATURE IS SUBJECT TO DISCIPLINARY ACTION = = =
Date employee may return to work
Physician’s Name:__________________________________________
Telephone:___________________
(Do not indicate indefinitely)
Address:_________________________________ City________________ State_____ Zip Code___________
____________________________
Signature:__________________________________________
Date: ______________________________
SEH-3 Part 2 (Rev. 11/11) Comm. Code 61602445418

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