Op 198 Form PDF Details

In the realm of education and employment within the New York City Department of Education, the Application for Excuse of Absence for Personal Illness, more formally known as Form OP 198, represents a critical procedural document. It operates under the jurisdiction of the Division of Human Resources and plays a pivotal role in managing personal illness (sick leave) requests of instructional staff across community and city districts. The form requires detailed documentation from the applicant, including specifics about the illness duration, days absent, and whether the leave is to be deducted from the Cumulative Absence Reserve (C.A.R.) or a sick bank. Moreover, for absences extending beyond 20 consecutive school days or in cases requiring confidentiality, medical certification thoroughness escalates, necessitating a comprehensive review by a licensed physician or another authorized practitioner. Notably, the form also accommodates scenarios beyond personal illness, covering allowances for children's diseases, alleged line of duty accidents, and unpaid leave, thereby encapsulating a wide spectrum of absences within the educational staff domain. The bureaucratic process underscores a robust system aimed at ensuring the health and wellbeing of the educational workforce, facilitating a structured mechanism for leave authorization while maintaining a balance between employee rights and educational integrity.

QuestionAnswer
Form NameOp 198 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesop198 uft, form op198, op 198 form, op 198 form doe

Form Preview Example

 

 

 

 

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NEW YORK CITY DEPARTMENT

OF EDUCATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DIVISION

OF HUMAN

RESOURCES

 

 

 

 

 

RCS PA8Cl4,5

 

 

 

 

 

 

 

 

 

 

 

 

65 Court

Street, Brooklyn,

N. Y. 11201

 

 

 

 

 

;

 

 

 

 

 

APPLICATION

FOR

EXCUSE OF ABSENCE

FOR

PERSONAL

ILLNESS

(SICK

LEAVE)

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

!

 

 

 

 

 

 

D-

Community District

 

 

 

 

D

 

-City

District Instructional

Staff

 

 

 

 

0

-For

Information

of Medical

Division

 

 

 

 

 

 

 

D

-Request for Medical

Evaluation

 

 

 

 

 

Read rules on reverse and type separate application for each non-consecutive absence in month.

 

I. To be Com

 

 

 

School

Secretar

 

licant:

 

 

 

 

 

 

 

 

 

 

 

 

 

Full

Name

an

ome

 

ddress of Applican

 

 

 

School Number

or Name and School Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

ZIP

 

File

#

 

 

 

 

 

Social

Security

#

 

 

 

 

 

 

 

 

 

School District

#

 

 

License

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Years of Service

 

 

 

 

 

 

 

ointed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-Per Diem Substitute

 

 

 

 

 

 

From

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Illness Since

 

s

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

September

 

 

*~:

For

per diem

substitute

show

only

days during which

applicant

would

otherwise

have

been employed

in position

held

 

immediately prior to absence to be excused.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dates

on

which

absence

 

Month.l

2 3 4 S 6

7

8 9

10 11 12 13 14 IS

16 17 18 19 20 21 22 23 24 2S 26 27 28 29 30 31

 

occurred.

 

Write

 

name

of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

month. Check with an "X"

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

those days on which absence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

occurred.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

licable item and indicate all necessar data called for under each item checked:

 

 

 

 

 

 

 

 

 

DAYS EXCUSED WITH PAY FOR PERSONAL ILLNESS DEDUCTIBLE FROMC.A.R. OR SICK BANK**

 

 

**NQ1e.: Per diem substitute must surrender sick leave credit certificate dated prior to date of absence.

 

 

 

 

 

 

(C.A.R. and Self-Treatment data to be omitted below.)

 

 

 

 

 

 

 

 

 

 

 

 

 

C.A.R.

on Initial

 

Day of Illness

 

 

 

Self- Treated Days Used This Year or Term

 

 

 

 

I&s.s. Sick Days

Now Claimed

 

 

-PlY.!

 

Self-Treated

Days Now Claimed

 

 

 

+

 

Balance

of Days

Left

in C.A.R.

 

 

 

Total Self-Treated

Days Used

 

 

 

 

 

 

Minus

Balance

Shows Borrowed

Da

s

 

Total "Self-Treated"

for Personal Business

 

 

 

 

B-

 

 

DAYS EXCUSED

WITH

PAY AND WITHOUT

LOSS OF SICK LEAVE FOR CHILDREN'S DISEASES

 

 

 

Applies to rubeola, epidemic parotitis or varicella but not to rubella.

 

 

 

 

 

 

 

 

 

 

 

 

C-

 

 

DAYS EXCUSED

WITH

PAY AND WITHOUT

LOSS OF SICK LEAVE FOR ALLEGED LINE OF DUTY

 

 

ACCIDENT

-Report

of .Injury

and Assignment (OP 200) must be filed

prior

to this application.

 

 

 

 

 

D-

 

 

DAYS

EXCUSED

WITHOUT

PAY. Does not apply to per diem substitutes.

 

 

 

 

 

 

E-OTHER:

II. To be Completed by Applicant (Check Only as Applicable): -Self-Treated Days (if shown) are claimed for:

-Confidential Medical R~ort (OP 407) substituted for Section IV and mailed directly.

-I

wish to borrow

sick days to be repaid or constitute a debt to the D~artment

of Education.

 

 

..

-I

did

 

J

 

report

for

duty to

any afternoon or evening activity of the Department

of Education

or

.

-I

did not

1

 

Community Board

on any date for which excuse is requested.

 

 

 

 

Date

 

 

 

 

 

 

 

 

Signature

of Applicant

 

 

 

 

 

 

 

leted

by Princ.

 

 

 

 

 

 

 

 

 

 

 

 

 

ithout

 

medical

 

 

 

 

 

 

edical

evaluation

 

 

 

 

 

 

 

 

 

 

-Disapproved for reason(s) indicated:

 

 

 

 

 

Date

 

 

 

 

 

 

 

Signature

of Principal

 

 

 

 

 

 

IV. To be Completed by Physician or Other Authorized Practitioner (OP 407 is to be substituted for absence exceeding

 

20 consecutive school days or when report is confidential):

 

 

 

 

 

MEDICAL

CERTIFICATION:

As a duly licensed

physician

or other authorized practitioner,

I certify

that between the dates

 

 

 

 

 

and

 

 

 

the person named above was incapacitated

for school duties and that I

attended the individual

on the following

dates:

 

 

 

.The technical designation of illness was:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

,

commonly

known as:

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician's

Address

 

 

 

 

 

 

 

 

 

 

Tel~one

 

Typed

or Printed

Name

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

Signature

of Phvsician,

 

 

 

 

, M.D.

(If other than M.D.,-'p!ofessional

title

is:

 

.)

 

 

 

 

 

V. To be Completed by Medical Division and Returned to School as Necessary:

 

 

 

 

 

 

Medical

Recommendation Submitted as Noted

1 -Medicalir

Ap proved

 

1 -MedicallY

Dis~oved

 

Subject to All

Administrative

Requirements

From

 

To

 

From

To

-Ordinary Illness (Item A or Item D)

 

 

 

 

 

 

 

 

-Enumerated Children's Disease (Item B)

 

 

 

 

 

 

 

-Alleged Line of Duty Accident (Item C)

 

 

 

 

 

 

 

-Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-Individual not to return to duty without further recommendation of Medical Division.

 

 

 

 

Additional

Remarks:

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

S~nature

of Medical

Director

 

 

 

 

 

25-2800.10.9

(500

Pkgs.)

7/93

 

 

 

 

 

Form OP 198 (2-71

-Replaces OP 199. OP 199A. OP 201 Item I)

COpy 1 -FOR MED DIV.JSION WHEN FORWARDED

 

 

 

 

 

 

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

,

""

 

 

 

 

 

 

 

 

 

 

 

 

GENERAL

RULES AND INSTRUCTIONS_,

 

 

 

 

 

 

 

~eRara&e

ARRlica&ign:

When

~~~9~1~~i,s~eq~ired,

'"

it

must \i;

submitted

to

pr!qc ~pal,

for each nl?n-co~~~~,,';Itlve absen<::;e

mmonth.

 

 

 

-,

,"-

 

 

 

,-'

 

 

 

 

'0"";""

 

 

 

 

Medical

Certification:

Must

be completed

by

physician

in

SectiQil:~.lVfQr abseJ)ce up

to.2<1 cons~~utive

school 'days 1IDlw"

physician

desires

10

submit confidential

report

on Form OP 4"07; Confidential

report

(OP 401)

~ust be

submitted for

absence-exceeding

20

consecutive

~chool

days.

Section IV

may

be omitted

when Form OP40Tis

submitted or -for self-

treated illness.

 

 

 

 

 

 

 

 

 

 

 

 

"

 

 

 

 

 

 

 

Medical

Division

AoRrllval:

The

principal,

Qr other

appropriate

supervisor,

may "grant sick

leave

with

pay

deductible

from C.A.R. or

sick

credit

of up

to 20 coniSecutive schoo"

days

of ordinary

illness

witltOQt

MedicatDivision

approval

unless he requests such evaluation in doubtful cases or "where lay judgment is jnS11fficient. The Medical Divitiion may

initiate evaluation

and maketecommendatidhs

whenever

medicallylndicated.

Applications

m!1rked "Request

for

Med-

icaIEvaluation"

must

be. submitted

for

abs;ericeexce~qing20

c~nsec~tive

school

da):s

and,

regardtess

"of

duration,for

',chil"dren 's:"di~~asesapd

.aUe.ged li~'of

dutya'C~idents;;~IS:<5

for a!>s:nce e~c:e?ing i 0

cons~cutive ,schoot

days

.at the .option

of the princIpal.

ApplIcatIons

mark;ed "For TnformatIQn of MedIcal DIvIsIon" ,must be submItted for ordinary Illness

granted by the principal forotdinary iUness of 1 t to 20 consecutive S1;hooldays.

 

 

 

 

 

 

 

 

CoRi~s: For ordi~ary

i.llness

up to

ten

consecutivesch"ool

days

(exclusive

of children's

diseas"es ijnd

line

of

duty

acci-

dents), originat (Copy 1) is retained in schqol and duplicat~ (Copy 2) is discarded. For all other cases bJ!1h copies are

forwarded to the MedicalDivision.

~

SPECIAL RULES AND INSTRUCTIONS

If IOU are a re~ularlI aRRointed member oftbe instructional 5taff.Iou maI a~RII for:

I.(Item A) up to 10 self-tre~ted days with pay in a school year (3 pf Which may be excused for personal business)

within ~our'C:A;R.ba}ance; AP1?Jtcation (OP }98} forql?e~ only be;used -wheff request~.d by pri~cipal,fot~.as"es where sick leave cannot be entered and co~l:Itersigned dIrectly on school record. In SectIon I, complete data for

charge to C.A.R. and also for self-treated days and, in Stction II, check self-treated days and "give reason (e.g..

:'cold" or "personal business"). Not :granted WRenother activities are engaged in en the same day; -~

l"

'

2.(Item A) Up. to yollr C.A.R.balance ~ith pay.. (C..&.R.may not e~ceed 290 attend of any&chool year.);W"hen not

self-treated, illness must be certified by physician in S~tion IV or by collfidential i:nedical report (see "Medk!\l

Certification" above). In Section I; compl_et~ data for charge,to C.A.R.. When C.A.R: is ~xha.usied, yl:ru maybor-

"

row up to 10 additional days which sho.w a~ a ~ in your C.A.R. balance; Except for one day a school year,

excuse with pay may not be granted for medical examination ot i~boratory 1est which could hav~ been; taken out- side of school hours; if physician indicates in Section IV/ that examination or test required school hQut:~ however.. pay may be granted. Excuse witl1pay may be granted for conditions related to pregnancy.

./

J. (Item B) Excuse with pay and without charge to C.A.R. for rubeola (measles), epidemic parotitis (mumps) or vari-

cetla (Cbick~!l po~) but Wlj;Jrubella {German measl~s). Section.IV or OP 407 required regardless of number of days."

,

/

c

"4, (Item C) Excuse with pay and without charge toC.A.R. for alleged acci"dent in line of duty." Pay may be granted

only if "Report of In~ryto Member of Profemonal Stlicff." (due withi~ 24 hours) and Assignment (Form OP 200) have been filed.. Section W'Of OP 407 requir.ed regardless of numbe~ of days; even though absence is non-consec-

utive, 9!lIYQnerncedi"al certification or report is required'tocover a reasonable period.

5/ {Item D) Excuse without pay ,(with payment only for days when;school is WIj; in .session) up to a reasonabl.enum-

ber in co,nneC"tion wit~ illnes.s for Which excuse with- pay is prQhibited (including days on which you reported for

other paid activiiies)St;l., in-cases of prolonged il.lness; up to one calendar month follQwingexhaustion of-:C:A,R.. (Should iltDess require longer aDsence, you must apply for and accept Leave of Ab~ence Without Pay "for Restora.

tion of" Health.) Section IV or OP 407 required regardless of number of days.

"

rent school term- of emgloIment:

6.(Item A) ~xcusecovered by Rule #1 R[ovided you are emptoyed for a full &~,~90t,yellr; if you are emplpyed for

oneteftn, you may appty only

for 5 self-treated days.

'

""

;"

""

 

7.,,(It~mA) ~xcuse covered by ,,~ule #2 ~ that yourC.A.R. may not exceed 120 days at the end of~ny scho?1

year and that you

may not

borrow additi9nal

sick days.

'

 

 

~. (ItemB}Excuse covered by Rule #3;

 

 

 

 

9: (Itelfi C) Excuse covered

by Rule #4. but need not have served preceding

five

days.

 

 

"'-

 

 

"

~

~10. (Item D) Excuse

covered by Rule #5 ~

that

extend~d,excQ~e

of

up to one calendar month without pay is not

granted:

 

 

 

"

 

 

"

11.(Item A) Excuse covered by RJIle #2 Rrovided Per Diem Certificate of Sick Leave Credit dated prior to date of il.l-

ness is surrendered to principal..~,

/0

11; {Item B) Excuse c9vered by Rute #3;.

"~

13.(Item C) Excuse covered by Rule #4.

"

14.(Item D.) Ex{)use of absence without pay is ndtgrantedper di~ substitutes.

" ,

N.B. Item E is not to be used ex~ept as provided by separate'regulation for special cases such as reveTsion from Ter-

"

"

minal Leave to ordinary sick l~~ve.

~

I

!

,

I

I

II

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op 198 writing process described (stage 1)

2. Right after filling in the previous part, go to the subsequent stage and complete all required particulars in all these blank fields - Balance of Days Left in CAR, Total SelfTreated Days Used, Minus Balance Shows Borrowed Da s, Total SelfTreated, for Personal Business, DAYS EXCUSED WITH PAY AND WITHOUT, Applies to rubeola epidemic, DAYS EXCUSED WITH PAY AND WITHOUT, ACCIDENT, Report, of Injury and Assignment OP must, D E OTHER, DAYS EXCUSED WITHOUT PAY Does not, II To be Completed by Applicant, and Check Only as Applicable.

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People who work with this PDF generally make errors when filling out DAYS EXCUSED WITH PAY AND WITHOUT in this area. Don't forget to reread whatever you type in here.

3. This third part is going to be straightforward - fill out every one of the empty fields in commonly known as, Physicians Address Typed or, Date If other than MDpofessional, Signature of Phvsician, title is, V To be Completed by Medical, Telone, Medical Recommendation Submitted, Medicalir Ap proved, MedicallY Disoved, From, From, Ordinary, Illness Item A or Item D, and Enumerated Childrens Disease Item B to conclude this process.

Stage no. 3 of submitting op 198

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