Name __________________________________________        Site ________________________

Assignment  _____________________________________________________________________

Nature of Illness __________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Name of Chief Attending Physician  __________________________________________________

Address of Physician ______________________________________________________________

Phone number of Physician _________________________________

This request must be accompanied by a signed diagnosis and prognosis report from your primary attending physician. Additional information may be requested by the Catastrophic Sick Leave Committee.

All information received will be held in the strictest confidentiality.

Return to: Catastrophic Sick Leave Bank Committee care of Personnel Services Office.