Download Date - World Bank

P.O. P.O. Box 6248
Broomfield, CO 80021
Application for Sick Leave for Absence Over 20 Working Days
For Staff Member to Complete
FAX To: (518) 880-6889
Please note: If you have accrued sick leave, you must receive approval from the Reed Group to use your accrued leave.
Staff Member’s Last Name
Staff Member’s First Name
UPI No.
Home Address (include country and postal code)
Home Phone Number (+ country/city codes)
Mailing Address (if different from above)
Cell Phone Number:
Email Address:
Height
Weight
M
Name of Direct Manager
Job Title-list the duties of your occupation at the time of your sick leave; if you
have a job description, please attach.
Gender:
F
Current number of hours of accrued sick
leave:
Work Phone Number
Manager’s Email Address
If approved, when you exhaust your sick leave, you
will automatically receive Supplemental Sick
Leave at 70% of your net salary.
Appointment Type:
Regular Staff
Term
Fixed-Term
ETT, ETC, STT, STC- not eligible for sick leave except
workers’ compensation.
GENERAL INFORMATION
Date you first noted
symptoms of your illness or
date of accident:
Date when you became
unable to work because of
this illness or injury:
Date you expect to return to
work:
Already returned to work?
Full-time?
Part-time?
If the illness/injury is related to your work, was a Workers’ Compensation claim filed?
Was the Bank Headquarters Security or Country Office Security notified?
Yes
Yes
Is this illness or injury was
related to your work at the
Bank?
Yes
No
Pending
No
TREATMENT
Date you were first
treated for your illness
or injury?
Give name and address
of hospital and doctor.
Have you been treated
for a similar condition
in the past?
Yes
No
Hospital Name
Fax No.
E-Mail
Fax No.
E-Mail
Address (Street, City, State, Postal Code)
Doctor’s Name
Telephone No.
Address (Street, City, State, Postal Code)
Hospital Name
Telephone No.
Fax No.
E-Mail
Fax No.
E-Mail
Address (Street, City, State, Postal Code)
Doctor’s Name
If Yes, give name and
address of hospital and
doctor.
Telephone No.
Telephone No.
Address (Street, City, State, Postal Code)
No
AUTHORIZATION FOR RELEASE OF PERSONAL MEDICAL RECORDS FOR SICK LEAVE OR WORKERS’ COMPENSATION
SICK LEAVE
I hereby authorize all physicians and health care professionals, hospitals and other healthcare institutions,
insurers, employers, and group policy holders to provide Reed Group, acting on The World Bank Group’s
behalf, with information concerning my health care, history, examination, treatment (including but not limited to
copies of my medical records), advice, and supplies provided to me, and any employment-related information
regarding my primary and/or secondary diagnoses related to my sick leave/workers’ compensation claim. I
understand that this authorization is valid until I submit written revocation to Reed Group. I hereby release any
person or entity providing information from any and all liability for furnishing such information. I agree that a
photographic or facsimile copy of this authorization is as valid as the original. I agree that this authorization is
valid for the duration of this illness/injury.
IMPORTANT NOTICE: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities
covered by GINA Title II from requesting or requiring genetic information of employees or their family members. In order to comply
with this law, Reed Group is asking that you not provide any genetic information when responding to this request for medical
information. ‘Genetic information,’ as defined by GINA, includes an individual’s family medical history, the results of an individual’s or
family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and
genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or
family member receiving assistive reproductive services.
If required, the Reed Group will coordinate with the Health Services Department (HSD) of the World Bank
Group regarding my return to work and that medical information (not complete medical records) will be shared
by the Reed Group with relevant staff within HSD only.
AUTHORIZATION FOR ASSIGNMENT OF BENEFITS
I understand that any amounts payable under The World Bank Group sick leave or workers’ compensation program for which I am
applying will be made by The World Bank Group, to be distributed by The World Bank Group to me, as appropriate.
I, the undersigned, certify that the information provided by me is complete and true. I understand that World Bank Group benefits are
subject to audit, and I understand that any misstatements made in this claim application may result in disciplinary measures, per Staff
Rule 8.01 which may include criminal and/or civil penalties.
I do not want any medical information shared with the Health Services Department (HSD).
Please note that HSD may be unable to effectively intercede on your behalf should you need accommodations to return to work.
Staff Member's Signature:
Date:
Print Staff Member Full Name:
Signature of Authorized Person *
Relationship of Authorized Person to Staff Member
* An authorized person must have a legally recognized relationship with the staff member, e.g., spouse or legal guardian, and the staff member must be rendered
incapable of signing for him or herself, due to the seriousness of their medical condition.
Please complete and return this form immediately to:
Reed Group
PO Box 6248
Broomfield, CO 80021
Email: [email protected]
Reed Group | PO Box 6248 | Broomfield, CO 80021 | Ph: 202-473-1907 | Fax: 518-880-6889
Document1
«AbsenceID»
ATTENDING PHYSICIAN'S STATEMENT
IMPORTANT:
FAX To: (518) 880-6889
If claim form is not completed in full, processing of benefits may be delayed until all required information has been received.
Write “NA” in non-applicable fields.
Patient's Full Name
Physician’s Name
Gender
M
F
Date of birth
Telephone No.
Fax No.
UPI No (provided by
claimant)
E-Mail
Physician’s Address (Street, City, State, ZIP, Country)
When did symptoms first
Date you believe patient was first
appear or accident happen?
unable to work
(mm/dd/yyyy)
(mm/dd/yyyy)
Is condition due to, or exacerbated by, injury or sickness arising out of
patient’s employment?
Yes No
Unknown
Has patient ever had the same or similar condition?
Yes
No If yes, state date and describe
Names and addresses of other treating physicians:
If yes, please explain:
Diagnosis (including any complications) Include ICD9, DSM
Subjective Symptoms
Objective findings (include current x-rays,
EKGs, lab data and any clinical findings)
Height:
Weight:
Blood pressure last visit (Systolic/Diastolic)
Date of first visit for this illness or injury with
you (mm/dd/yyyy)
Date of last visit
(mm/dd/yyyy)
Date of next visit
(mm/dd/yyyy)
If pregnancy, expected delivery date
or actual delivery date
(mm/dd/yyyy)
Frequency of visits
Nature of Treatment (including surgery, CPT and medications prescribed, if any)
INFORMATION ABOUT THE PATIENT’S INABILITY TO WORK (This information is critical to understanding your patient’s
condition)
First date of sick-leave
(mm/dd/yyyy)
What is your prognosis for recovery?
Has patient achieved maximum medical improvement?
Yes
No
If No, how soon do you expect changes in the patient’s
medical condition?
1 – 2 mo.
3 – 4 mo.
5 – 6 mo.
+6 mo.
Is patient:
Ambulatory
Bed Confined
House Confined
Hospital Confined
Does patient’s condition prevent him/her from caring for
himself/herself?
Yes
No
If Yes, please explain and provide supporting
documentation
Has patient:
Recovered
Improved
Unchanged
If Unchanged or Regressed, please explain:
When do you expect patient to recover?
Reed Group | PO Box 6248 | Broomfield, CO 80021 | Ph: 202-473-1907 | Fax: 518-880-6889
Document1
«AbsenceID»
Regressed
2 weeks
1 month
1-3 mo.
3 – 6 mo.
Reed Group | PO Box 6248 | Broomfield, CO 80021 | Ph: 202-473-1907 | Fax: 518-880-6889
Document1
«AbsenceID»
Never
CARDIAC (if applicable)
Functional capacity (American Heart Association)
Class 1 (no limitation)
Class 3 (marked limitation)
Class 2 (slight limitation)
Class 4 (complete limitation)
If employer is able to accommodate patient’s
limitations and restrictions, is this patient able to
return to work?
Activity capacity
C. (moderate restrictions)
A. (no restrictions)
D. (marked restrictions)
B. (slight restrictions)
E. (complete restrictions)
When can patient return to work? (mm/dd/yyyy)
Or, does patient need to be reviewed? (mm/dd/yyyy)
Yes
No
Part Time (no of hours per wk)
Full time
Work Restrictions/Limitations (what the patient should not and cannot do):
Please specify any work accommodations, if needed:
Are you, the physician, related to this patient?
Yes
No
REQUIRED ATTACHMENTS: Make sure that office notes, test results &
discharge summaries are attached. This will help reduce additional
requests.
FRAUD NOTICE: I, the undersigned, certify that the information provided by me is complete and true. I understand that any person
who knowingly files a statement of claim containing any false or misleading information may be subject to criminal and civil penalties.
Name (Attending Physician)
Degrees & Specialty
Physicians Signature (no stamp)
Date (mm/dd/yyyy)
Please see ADDENDUM for Genetic Information Nondiscrimination Act. DO NOT PROVIDE GENETIC INFORMATION.
Please complete and return this form immediately to:
Reed Group, Ltd.
Reed Group
PO Box 6248
Broomfield, CO 80021
Email: [email protected]
Reed Group | PO Box 6248 | Broomfield, CO 80021 | Ph: 202-473-1907 | Fax: 518-880-6889
Document1
«AbsenceID»
. PO P.O. Box 6248
Broomfield, CO 80021
Addendum – GINA Notification
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II
from requesting or requiring genetic information of employees or their family members. In order to comply with this law, we are
asking that you not provide any genetic information when responding to this request for medical information unless, with respect to
leave to care for a family member with a serious health condition, failure to provide the information will result in an incomplete or
insufficient certification. ‘Genetic information,’ as defined by GINA, includes an individual’s family medical history, the results of an
individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic
services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by
an individual or family member receiving assistive reproductive services.
Reed Group | PO Box 6248 | Broomfield, CO 80021 | Ph: 202-473-1907 | Fax: 518-880-6889
Document1
«AbsenceID»
Release to Work Form
Instructions: Prior to returning to work from a Workers’ Compensation or Short Term Disability Leave, you must:
1. Present a signed copy of this form to the Reed Group
2. Fax this form to Reed Group at 518-880-6889;
3. If work accommodations are required, the recommendations should be listed on this form.
All work accommodations must be reviewed and approved by Reed Group, HSD, and your manager prior to return to work.
Staff Member Name: (Please Print)
Part I - To be completed by Staff Member
UPI #:
Part II - To be completed by Medical Provider – Please do NOT list diagnosis or nature of illness/injury
I certify that this staff member is medically fit to return to work on (date): _____________
The staff member’s medical condition
will (Please complete Part III) OR
perform all of the regular functions of his/her position.
will not (skip to Part IV) continue to impact his/her ability to
If temporary accommodation(s) are necessary, the projected full duty release is (date): _______________
Part III – Abilities – To be completed by Medical Provider
Is the staff member able to work a full work schedule (ie- 40hrs/ week)?
Yes
No
If no, please complete the following information:
How many hours can the staff member work per day?
2hrs/day
4hrs/day
6hrs/day
Other : ______ hrs/day
How many days per week can the staff member work this schedule? _______ days/ week
Kindly advise if other accommodations are needed for a successful return to work (ie- telecommuting, lifting, sitting, standing, etc):
Please note: Operational travel is not allowed when a staff member is on a modified schedule.
Is travel to be limited when staff member is returned to full duty?
Yes
No
If yes, please provide specifics:
Attending Physician’s Name: (Please Print)
Attending Physician’s Signature:
Part IV - Medical Provider Information
Attending Physician’s Phone Number:
Date:
Please see ADDENDUM for Genetic Information Nondiscrimination Act. DO NOT PROVIDE GENETIC INFORMATION.