Cld 9N Form PDF Details

Clinical laboratory scientist are responsible for performing diagnostic tests on patient specimens in order to provide physicians with information needed to diagnose and treat patients. A career as a clinical laboratory scientist can be both rewarding and challenging, but it is also a field that is constantly evolving. In order to stay up-to-date on the latest technologies and procedures, it is important for clinical laboratory scientists to continue their education and training throughout their career.Recently, the American Society for Clinical Pathology (ASCP) introduced a new certification exam known as the Clinical Laboratory Scientist 9N Form. This exam is designed to assess the knowledge and skills of clinical laboratory scientists who work in blood banks and transfusion services. If you are interested in obtaining this certification, here is some important

QuestionAnswer
Form NameCld 9N Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namessss form notification, sss form sickness, sss sickness notification form 2021 editable, sss form sickness download

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Address of Employer:

Republic of the Philippines

SOCIAL SECURITY SYSTEM

SICKNESS NOTIFICATION

SSS Form CLD-9N (Rev. 10/74)

I M P O R T A N T

BEFORE ACCOMPLISHING

PLEASE READ INSTRUCTIONS

S N NO.:

PART I

CONFINED MEMBER’S NOTIFICATION

 

 

 

 

 

 

 

 

 

Date :

(This Block to be accomplished by confined member. Please print all data.)

 

 

 

 

 

 

 

 

Name of Confined Member:

SS Number:

 

Tax Account Number:

 

 

 

 

 

 

 

Name of Employer:

 

Residence:

 

 

 

 

Exact Date

Confinement

Started

Place/Address of Confinement:

This is to notify my employer that I am currently confined. The name of my employer, the place/address and the date when such confinement started are indicated above. I certify that I am hereby waiving in favor of the SSS all information which my physician has acquired while attending to me as a patient in a professional capacity which information was necessary to enable him to act in that capacity. I hereby consent to the examination of my physician as to all information acquired by him from physical/mental examination of my person and all results of X-ray, laboratory, and/or special diagnostic examination. I further waive all information held privilege by law.

Name & Signature of member’s Authorized Representative

(IF SICK MEMBER CANNOT WRITE: PRINT RIGHT THUMBMARK)

(Signature of Confined Member)

(Please sign over your printed name)

(RIGHT THUMBMARK)

P A R T II M E D I C A L C E R T I F I C A T E

 

 

Date:

(This Block to be filled by the Attending Physician)

 

 

 

I CERTIFY THAT I HAVE EXAMINED/ATTENDED TO the above-named employee and state the following:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. (a) Exact Date Examined/Attended:

 

 

 

 

 

 

(b) Age:

 

 

(c) Sex:

 

 

 

 

 

 

 

(d) Civil Status:

(e) Occupation:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Address of Confinement :

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. THIS IS BEING SUBMITTED AS: (Check applicable box &

state corresponding report/findings.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

an INITIAL certificate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

an INTERMEDIATE certificate

 

 

a FINAL certificate

 

 

 

CLINICAL SUMMARY: (Please read accompanying instructions.)

 

 

 

3(a) PROLONGED CONFINEMENT DUE TO:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Give progress report of patient)

 

 

 

 

 

4. DIAGNOSIS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4(a) FINAL DIAGNOSIS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IN MY MEDICAL OPINION the confinement including the conva-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO. OF DAYS OF CONFINEMENT EXTENSION (days)

 

 

 

lescing or recuperation period may last for ________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

days. FIT TO RESUME WORK ON _______________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EFFECTIVE (Exact Date)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Estimated Date)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Confinement NOT VERIFIED by employer/company physician

CONFINED AT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Confinement VERIFIED by employer/company physician

 

 

 

 

WILL BE FIT TO RESUME WORK ON (Exact Date)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRINTED NAME & SIGNATURE OF ATTENDING PHYSICIAN

 

 

 

 

PRINTED NAME & SIGNATURE OF EMPLOYER/COMPANY PHYSICIAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REGISTRATION NO.

 

 

TELEPHONE NO.

 

 

 

 

REGISTRATION NO.

 

 

 

 

 

TELEPHONE NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(PART III of this form at back also to be filled up)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER’S/COMPANY’S ACKNOWLEDGEMENT RECEIPT

 

 

 

 

 

 

 

 

EMPLOYEE’S ACKNOWLEDGEMENT RECEIPT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(FROM SSS)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(FROM COMPANY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Confined Member:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Confined Member:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONFINEMENT PERIOD (Exact date)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

START OF CONFINEMENT (Exact Date)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RECEIVED BY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTIFICATION RECEIVED BY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE RECEIVED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE RECEIVED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Internet Edition (7/2000)

PART III

(THIS BLOCK TO BE FILLED BY EMPLOYER)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. His/her confinement

 

2. Sickness Notification was received by us on _________________________ 19____

started:

 

 

thru:

 

 

 

 

 

 

 

 

(Exact Date)

 

 

Phone, rec’d by ____________

 

 

Handcarried by ____________

Mail ____________

 

 

 

 

(Date) ___________________

 

 

(Date) ___________________

(Postmark Date)

 

 

 

 

 

 

 

 

 

 

 

3. Sickness occurred while:

 

 

 

 

 

 

 

 

 

working

 

in company premises

on leave

under suspension

on strike

 

company’s “shut

 

 

 

 

 

 

 

 

 

 

 

 

down”

other reason (s) ______________________________________________________________________________________________

 

 

 

 

 

 

 

 

4. COMPANY HAS NO WAY OF VERIFYING THE SICKNESS BECAUSE:

 

 

 

 

 

 

 

 

 

 

 

 

He/she notified us only upon returning to work on _______________

Company has no physician

 

The place of confinement was in ____________________ which is ___________ kms. away

 

 

 

 

 

 

 

 

 

 

 

 

 

Company ID Number

 

Sign

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

____________________

 

Here

_______________________________________________

 

 

 

 

 

 

 

 

 

PRINTED NAME & Signature of Company Executive

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL EVALUATION

 

 

 

(Do not fill this block. For SSS use only)

 

 

 

 

 

 

 

 

 

 

 

 

FINAL DIAGNOSIS:

 

 

 

 

 

 

 

 

 

 

 

APPROVED:

____________ days, from _________________ to _________________

 

 

 

RECONSIDERATION/EXTENSION

 

 

 

 

 

 

 

 

 

 

REDUCED:

 

____________ days, from _________________ to _________________

No. of Days ____________________

 

 

 

 

 

 

 

 

 

 

DENIED:

 

__________________________________________________________

From:

____________________

 

 

 

 

 

 

 

 

 

 

Claimant to come for physical examination/chest X-ray in the morning only. Bring SSS Form E-1

To:

____________________

 

 

 

 

 

 

 

 

 

 

or SSS ID.

 

__________________________________________________________

 

 

 

 

 

 

 

 

 

Submit:

 

__________________________________________________________

(Date)

 

MEDICAL EXAMINER

Returned:

 

__________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PREVIOUSLY APPROVED CONFINEMENT PERIOD: From: ____________ to ____________________________

 

 

(Exact Date)

(Exact Date)

(No. of Days)

 

__________________________________

________________________________________________

 

(Date)

SSS Medical Examiner/Retainer Physician

 

 

 

 

IMPORTANT INSTRUCTIONS:

 

 

 

1 .

The employee shall notify his employer of his sickness or injury within five (5) calendar days after the start of his

 

confinement. The employer in turn shall notify the SSS Medical Department or the Medical Division of the nearest

SSSbranch of his employee’s confinement within five (5) calendar days after the receipt of the notification from his employee. However, in cases where the sickness or injury is sustained by the employee while working or within the premises of the employer, the employee shall be deemed to have notified his employer. In such cases, the 5- day period for the employer to notify the SSS shall start on the day immediately following the 1st day of sickness or injury. The foregoing prescription period of NOTIFICATION does not apply to HOSPITAL confinement.

2 .

This form, after having been properly accomplished, shall be submitted in two (2) copies to the Employer by the

 

sick employee or his representative. The employer shall submit the ORIGINAL to the SSS Medical Department or

 

the Medical Division of the nearest SSS branch, within the prescribed period in instruction No. (1).

3 .

This form is to be used for the purpose of an INITIAL SICKNESS NOTIFICATION and INTERMEDIATE or FINAL

 

SICKNESS NOTIFICATION, with the Attending Physician checking the proper box in PART II (Medical Certificate

 

portion) of this form.

4 .

For the items “CLINICAL SUMMARY” and “PROLONGED CONFINEMENT DUE TO” in PART II of this form,

 

symptoms, physical findings, laboratory examinations and reports; X-ray plates; special diagnostic procedures, if

 

any, must be submitted with this form. In cases of prolonged confinement, a progress report of the patient, in

 

addition to those already stated, must also be submitted. If spaces provided are not enough, attach an additional

 

sheet herewith.

5 .

In cases of prolonged confinement or sickness of the employee that will extend beyond the initial estimate, on a

 

previous estimated period, this form will be accomplished again by the employee and his Attending Physician,

 

and submitted to the SSS within five (5) days requirement, after the previous estimate, and the Attending Physician

 

will check the applicable boxes in PART II hereof.

6 .

For further details, refer to Circular No. 91-T, dated October 31, 1972, re: Sickness Notification requirements and

 

procedures.

7 .

Physical examination will be held only in the morning from 8:00 to 12:00, Monday thru Friday. Those who cannot

 

come should notify the SSS Medical Department or the Medical Division of the nearest SSS branch immediately.

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As a way to finalize this PDF document, make certain you type in the right details in every single field:

1. It's vital to complete the sss sickness notification form 2021 accurately, hence be mindful when filling out the segments including all these blanks:

sss sickness notification form 2021 editable conclusion process detailed (stage 1)

2. Just after the previous array of fields is completed, go on to enter the applicable information in these: I CERTIFY THAT I HAVE, d Civil Status, e Occupation, b Age, c Sex, Address of Confinement, THIS IS BEING SUBMITTED AS Check, an INITIAL certificate, an INTERMEDIATE certificate, a FINAL certificate, CLINICAL SUMMARY Please read, a PROLONGED CONFINEMENT DUE TO, Give progress report of patient, DIAGNOSIS, and a FINAL DIAGNOSIS.

Part no. 2 in filling out sss sickness notification form 2021 editable

Always be very mindful when filling out c Sex and a FINAL certificate, since this is where many people make errors.

3. Within this part, review EMPLOYERSCOMPANYS ACKNOWLEDGEMENT, EMPLOYEES ACKNOWLEDGEMENT RECEIPT, FROM SSS, FROM COMPANY, Name of Confined Member, Name of Confined Member, EMPLOYER, ADDRESS, ADDRESS, EMPLOYER, CONFINEMENT PERIOD Exact date, START OF CONFINEMENT Exact Date, FROM, RECEIVED BY, and DATE RECEIVED. Each of these need to be taken care of with greatest accuracy.

sss sickness notification form 2021 editable conclusion process detailed (step 3)

4. To go ahead, the next stage will require completing a few blanks. These comprise of PART III THIS BLOCK TO BE FILLED, Hisher confinement, started, Exact Date, Sickness Notification was, Phone recd by, Handcarried by, Mail, Date, Date, Postmark Date, Sickness occurred while, working, in company premises, and on leave, which you'll find vital to going forward with this process.

Filling in section 4 in sss sickness notification form 2021 editable

5. The form needs to be concluded by filling in this segment. Below you will find a comprehensive list of fields that need appropriate information in order for your form submission to be complete: Submit, Returned, Date, MEDICAL EXAMINER, PREVIOUSLY APPROVED CONFINEMENT, Exact Date, Exact Date, No of Days, Date, SSS Medical ExaminerRetainer, IMPORTANT INSTRUCTIONS, The employee shall notify his, This form after having been, and This form is to be used for the.

Stage number 5 for completing sss sickness notification form 2021 editable

Step 3: Soon after double-checking the fields you've filled out, click "Done" and you're done and dusted! Right after registering a7-day free trial account here, it will be possible to download sss sickness notification form 2021 or email it directly. The document will also be readily accessible through your personal account page with your each and every change. FormsPal provides risk-free document completion without personal data record-keeping or sharing. Rest assured that your information is in good hands with us!

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