Doctor Medical Leave Certificate California by jnq48892

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									California State University, San Bernardino
FURLOUGH ABSENCE AND ADDITIONAL                                                                                    PAY PERIOD                        TIME BASE                                          CBID                            ALTERNATE WORKWEEK SCHEDULE
                                                                                               1. MONTH                  YEAR                                                                                              4/10/40   9/8/8




TIME WORKED REPORT                                                                                 August                         2009                                                                                                              4/10/40                   9/8/80
2. NAME (First                                        Middle                                   Last)                                          3. Emp. ID #:                       Empl. Record #             4. Department

John                                                   A.                                                 Doe                                     000001234                                 0                                                 Accounting
5. ABSENCE WITH PAY
                    (S)          SICK LEAVE                     (B)                     BEREAVEMENT                (C)                  CATASTROPHIC LEAVE                                            (J)                JURY DUTY
                                 SELF                                                   LEAVE                                           DONATIONS RECEIVED AND USED                                                      (Make copy for Accounting)
                   (SF)          SICK LEAVE                     (TO)                    USING OVERTIME             (M)                  SHORT-TERM MILITARY
                                 FAMILY ILLNESS                                         CREDITS                                         LEAVE (Calendar Days) ____________________                    (SW)               SUBPOENAED WITNESS
                   (SD)          SICK LEAVE                     (TH)                    USING HOLIDAY                                   (Attach Military Duty Orders)                                                    PARTY                                       EXPERT
                                 DEATH IN FAMILY                                        CREDITS                    (NDI)                NONINDUSTRIAL INJURY
                                 (RELATIONSHIP)                 (TE)                    USING EXCESS                                                                                                               COURT                                      CITY
                                                                                        HOURS CREDIT               INDUSTRIAL ILLNESS OR INJURY (Report of Industrial Injury
                                                                (PH)                    USING PERSONAL                                                        must be submitted)
                   (PL)         PERSONAL LEAVE                                          HOLIDAY                    (TD)                 TEMPORARY DISABILITY                                                             NO FEES                              FEES TO BE
                                                                (SH)                    USING SATURDAY             (IDL)                INDUSTRIAL DISABILITY LEAVE                                                      RECEIVED                             REMITTED
                   (A/L)        ANNUAL LEAVE                                            HOLIDAY                    (IDL/S)              INDUSTRIAL DISABILITY LEAVE                                                      FEE RETAINED                         TO STATE
                                                                (E)                     PAID                                                 WITH SUPPLEMENTATION                                                  CHARGE ABSENCE TO
                    (V)         VACATION                                                EDUCATIONAL LEAVE                                                                                                                                                     ABSENCE
                                                                                                                   OTHER                _______________________________                                                  VAC                       CTO        WITHOUT PAY
6. ABSENCE WITHOUT PAY                                                                                                                                                                                                                             PAY PERIOD:
                     (L)        INFORMAL LEAVE GRANTED                        (A)              ABSENCE WITHOUT LEAVE                          ABSENCE WHILE                                (ML)       MENTORING LEAVE                                   QUALIFYING
                                (11 Working days or less)                                      (AWOL) (19996.2 OR 19572)                      ON PROBATION
                                                                                                                                                                                           (F)        FURLOUGH            NONQUALIFYING
                     (L)        INFORMAL LEAVE GRANTED                                         TEMPORARY LEAVE                                (FM) FAMILY AND MEDICAL                                      Regular Employment Status
                                                                                                                                              LEAVE (FMLA)
                                (15 Working days or less) (CSUC)                               (30 Calendar days or less)                                                                                     Exempt           Non-Exempt
7. DATES OF ABSENCES AND EXTRA TIME WORKED
   (Enter symbol and number of hours in date blocks. See reverse for legends and symbols note noted above. If the absence is for a compensable injury waiting period, add X to other symbol.)
       REPORTING           31      1        2     3         4         5   6         7      8      9     10    11     12      13    14    15     16     17     18    19       20     21    22     23     24    25    26               27       28    29   30     31              TOTAL
7A. HRLY INT/PT HRS
TO BE PAID

                                                10.0 10.0 10.0 10.0                                    8.0 8.0 8.0 8.0                               10.0 10.0 10.0 10.0                               8.0 8.0 8.0 8.0                                        10.0             154.0
7B.
       SICK = S

                                                                                                                                                                                                                                                                                0.0
7C.
 BEREAVE-MENT = B

                                                                                                                                                                                                                                                                                0.0
7D.
 VACATION = V

                                                                                                                                                                                                                                                                                0.0
7E.
        A/L

                                                                                                                                                                                                                                                                                0.0
7F.
TO,TH,TE,FM,PH,SH,

                                                                                                                                                                                                                                                                                0.0
E,M,SW,J,PL,ML


7 G.
        L, A, F

                                                                                                                                   F                                                                                                          F                                 0.0
7 H. STRAIGHT
     TIME, WO,

                                                                                                                                                                                                                                                                                0.0
     P, HC, WE


7 I. PREMIUM
     TIME
     WO, P
                                                                                                                                                                                                                                                                                0.00
8. THE FURLOUGH DATES THAT I OBSERVED DURING THIS PAY PERIOD ARE:                                                                       08    /      14       /         09               AND          08     /     28      /                  09
                                                                                                                                        MM           DD            YYYY                               MM           DD                        YYYY
                           I also confirm that I did not Work Excess hours during the weeks these furlough days were observed (unless indicated in Section 7H and/or 7I
9. CERTIFICATE BY EMPLOYEE                                                                                                                           EMPLOYEE SIGNATURE                                                 DATE
To the best of my knowledge and belief, the facts stated are accurate and in full compliance with legal and CSU
policy requirements.
                                                                                                                                              11. STATEMENT BY PHYSICIAN (Not to be completed by attending physician for
10. RECOMMENDATION AND SUBSTANTIATION OF SUPERVISOR                                                                                                industrial illness or injury .)
       APPROVAL                APPROVAL                                                                                                           DOCTOR STATEMENT ATTACHED
       RECOMMENDED            NOT RECOMMENDED                                                                                                      AS PHYSICIAN, I EXAMINED AND TREATED OR PRESCRIBED FOR
SUBSTANTIATION SHALL BE REQUIRED FOR SICK LEAVE OF MORE THAN TWO
CONSECUTIVE WORK DAYS. SHOW METHOD OF VERIFICATION BELOW.                                                                                     THIS PATIENT ON THESE DATES

                                                                                                                                              DATE OF RETURN TO WORK             IF STILL DISABLED, GIVE ESTIMATED DATE OF RETURN
                                                                                                                                                                                 TO WORK
SIGNATURE OF SUPERVISOR                                                                                DATE                                   THE ILLNESS OR INJURY CAUSING THE DISABILITY WAS

                                                                                                                                              SIGNATURE OF ATTENDING PHYSICIAN                                   DATE


              12. PERIOD ON DISABILITY COMPENSATION                           13. DISABILITY COMPENSATION SUPPLEMENT                                                                                         14. OFFICIAL DEPARTAMENTAL REVIEWED BY
FROM                                   TO                                                              SICK LEAVE                 VACATION           CTO                 HOLIDAY / CREDIT                                               ACTION
                                                                                    HOURS                                                                                                                          Approved
                                                                                                                                                                                                                   Disapproved

								
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