Sss Employee Notification Form – Fill Out and Use This PDF

PART 1 CONFINED MEMBER’S NOTIFICATION (To be fill up by confined member)

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 any person and all results of X-ray, laboratory, and/or special diagnostic examination. I further waive all information held privilege by law.

NAME AND SIGNATURE OF MEMBER’S AUTHORIZED REPRESENTATIVE

SIGNATURE OF CONFINED MEMBER

(RIGHT THUMBMARK)

(If sick member cannot write, print right thumbmark)

(Please sign over your printed

name)

PART II MEDICAL CERTIFICATE (This block to be filled by attending physician)

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

EXACT DATE EXAMINED/ATTENDED

AGE

SEX

CIVIL STATUS

OCCUPATION

ADDRESS OF CONFINEMENT

THIS IS BEING SUBMITTED AS: (Check applicable box and state corresponding report/findings)

an INITIAL CERTIFICATE

an INTERMEDIATE

a FINAL CERTIFICATE

CLINICAL SUMMARY (Please read accompanying instructions.)

PROLONGED CONFINEMENT DUE TO :

DIAGNOSIS

(a) FINAL DIAGNOSIS (Give progress report of patient)

IN MY MEDICAL OPINION the confinement including the convalescing or

NO. OF DAYS CONFINEMENT EXTENSION EFFECTIVE (Exact Date)

recuperation period may last for

days. FIT TO RESUME

WORK ON

(estimated date)

Confinement VERIFIED by employer/company physician

CONFINED AT

WILL BE FIT TO RESUME WORK ON (Exact Date)

Confinement NOT VERIFIED by employer/company physician

PRINTED NAME & SIGNATURE OF EMPLOYER/ATTENDING PHYSICIAN

PRINTED NAME & SIGNATURE OF ATTENDING PHYSICIAN

ADDRESS OF PHYSICIAN

ADDRESS OF PHYSICIAN

REGISTRATION/LICENSE NO.

REGISTRATION/LICENSE NO.

PART III EMPLOYER’S REPORT (This block to be filled up by Employer)

NAME OF CONFINED MEMBER

OCCUPATION (Exact description of work)

TIME OF WORK (Inclusive hours)

HOW LONG EMPLOYED?

Date of Employment

CAUSE OF INJURY

DESCRIBE FULLY HOW ACCIDENT HAPPENED AND STATE WHAT

(a) Machines or tool

EMPLOYEE WAS DOING WHEN INJURED.

(b)Kind of power (Hand, foot, electrical steam, etc.)

(c)Part of Machine on which accident occurred.

				Time, date & place of accident:
(d) Was he injured during his regular occupation?
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		DATE RECEIVED		NOTIFICATION RECEIVED BY	DATE RECEIVED

Internet Edition (7/2000)

CERTIFICATION BY EMPLOYER

NATURE OF BUSINESS	NO. OF EMPLOYEES					COMPANY ID NUMBER		PRINTED NAME & SIGNATURE OF COMPANY EXECUTIVE
	EMPLOYED
						FOR SSS USE ONLY
						MEDICAL EVALUATION
FINAL DIAGNOSIS
	APPROVED:			________________ days, from ________________ to ________________
	REDUCED:			________________ days, from ________________ to ________________
	DENIED:					____________________________________________
	CLAIMANT TO COME FOR PHYSICAL EXAMINATION, CHEST X-ray.
	Submit: ___________________________________ Returned: _________________________
PREVIOUSLY APPROVED CONFINEMENT PERIOD: From ________________ to ________________
(Exact Date)								(No. of Days)
SIGNATURE OF SSS MEDICAL EXAMINER/RETAINER PHYSICIAN										DATE EVALUATED
RECONSIDERATION/EXTENSION:			NO. OF DAYS				FROM	TO		MEDICAL EXAMINER	DATE

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. Within five (5) days from receipt of notice or knowledge of the sickness or injury, the employer shall record in his logbook the facts thereof and within five (5) days thereafter the employer shall notify the SSS Medical Evaluation Department or the nearest SSS branch or representative office. 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. 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 Evaluation Department/Division within the prescribed period in instruction No. 1.

3.Use this form 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 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 thereof.

6.For further details, refer to EC Circular No. 2-1 re: Sickness Notification requirement 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 Evaluation Department/Division immediately.