ࡱ>  y "bjbj *6{{   dd$l/XXXXX&......$0x3.".ddXXQ.SSSd8XX&S&SSnk$%X:qs% &.0/%hv4.v4@%v4%S..%./v4  *: MICHIGAN CIVIL SERVICE COMMISSION Disability Management Office 400 South Pine Street P.O. Box 30002 Lansing, Michigan 48909 NON-FMLA MEDICAL CERTIFICATION BY PHYSICIAN OR PRACTITIONER SECTION I ( Authorization to Release Medical InformationI authorize my (or my minor childs) attending physician or practitioner to release the information requested below in Section II to the employees employer regarding my (or my minor childs) physical or mental condition. This information will only be used as necessary to determine how it will affect the state employees work activity in consideration of the request for a leave of absence. By signing this release, I certify that I am authorized to request the release of this information and I understand that I am agreeing that the employer may obtain and use such necessary medical information provided below about me (or my minor child), including information relative to HIV or AIDS, if applicable. This information is retained confidentially, consistent with applicable civil service rules, collective bargaining agreements, and state and federal law.Employees Name Employees ID No. Patient Name Patients (or Guardians) Signature Date SECTION II ( Certification of Medical Condition by Physician or PractitionerThis portion is to be filled out by the health care provider to certify the need for the employees personal medical leave.Patient NameRelationship to EmployeeDate Off WorkProbable Return to Work DateDescribe the medical facts, including the diagnosis and prognosis, that support your certification:Regimen of treatment prescribed (indicate number of visits, general nature and duration of treatment, including referral to other provider of health services):Is inpatient hospitalization required? ( Yes ( NoIf the request is for the employees medical condition, can the employee perform the essential functions of their position? (Please answer after discussing with the employee.) ( Yes ( NoComplete this portion only if the patient is the employee: If the employee cannot perform their positions essential functions, explain whether the employee can perform work of any kind and what activities the employee can perform.If the leave is to care for the patient, explain the care the employee will provide and an estimate how long care will be needed.Name of Physician or Practitioner (Please type or print)Type of Practice (Specialization, if any)Signature of Physician or PractitionerDateAddress of Physician or PractitionerPhone Number CS-1835 2/2012 "#9?} g j s t x " 6 Y \ i ž}v}v}o}v}vh}dh`hvhvhhBAhC2 hC2h=/a hC2hwr hC2hC2 hC2hAhhFhAh5 jhFhAh5CJ h%q5CJhFhAh5CJhFh%q5CJhFhAh5CJ h=/a5CJhFhAhCJhFhwrCJ h=/aCJh%qhAh5aJh%qh%q5aJjh%qh%q5UaJ%#@Ve}S l` $$Ifa$gdBAqkd$$Ifl    9**  0    4 lap yt@k}$If $a$gdwr$a$gdd $a$gdwr i k { [   6 7 < B L N S T e f y { | } ̼ٶƓƶ̉x h=/a5CJhFh=/a5CJhh=/a>*CJ hBACJhFh=/a5CJhFh=/a>*CJhFh=/aCJ hXbCJhhAh>*CJ hCJ h>*CJ hO1CJhFhAh5CJhC2hBA hC2hAh hC2h=/a hC2hC2+S T | } fkd3$$Ifl4    ,9** 0    4 laf4yt@k} h(($IfgdoJckd$$Ifl    9**0    4 layt@k}} p h !(($IfgdXbfkd$$Ifl4    ,9** 0    4 laf4yt@k} hO(($IfgdXb !qkd!$$Ifl    9**  0    4 lap yt@k}$Iffkds$$Ifl4    ,9** 0    4 laf4yt@k} ` c <=?   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B S  ?" =t #  #       #       #   T"=L>0#R@Te ) +ܕ+F(= \Rtʺ=T3>P$Xf$Z[NY mPiHhdOtchh^h`.hh^h`56o(hH. hh^h`o(.hww^w`OJQJo(hHhGG^G`OJQJ^Jo(hHoh  ^ `OJQJo(hHh  ^ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHhWW^W`OJQJo(hHh''^'`OJQJ^Jo(hHoh^`OJQJo(hHh hh^h`o(hH.h88^8`OJQJ^Jo(hHoh^`OJQJo(hHh  ^ `OJQJo(hHh  ^ `OJQJ^Jo(hHohxx^x`OJQJo(hHhHH^H`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHhh^h`.hh^h`. hh^h`56o(hH.h hh^h`o(hH.h88^8`OJQJ^Jo(hHoh^`OJQJo(hHh  ^ `OJQJo(hHh  ^ `OJQJ^Jo(hHohxx^x`OJQJo(hHhHH^H`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHhh^h`.hh^h`.hh^h`56.hh^h`. 0#+[NY(=Ot\R T"P$XmPiTe )=T0+          j        $#d M :h#O1C2n6s>6BAN)O(`=/a!b9bAhYo%q?rwrFQs@k}~,]y4;x>kF+loJXb  V3*6*6V4*6*6V5*6*6V6*6*6V7*6*6 o (@Te&mplate MacrosCustom Popup 17600796P AP-09P-09WWWWW1( &Unprotect Form Protect FormProtectForm.ProtectForm% E'\Custom Popup 17600796 Custom Popup 176007961( &Protect/Unprotect Toggle Protect FormProtectForm.ProtectForm( &Spell Check FormForms Spell CheckFormsSpellCheck.FormsSpellCheck - AA'#TemplateProject.CheckText.CheckText/TemplateProject.FormsSpellCheck.FormsSpellCheck'TemplateProject.ProtectForm.ProtectForm9TemplateProject.ProtectForm.ToolsProtectUnprotectDocumentTemplateProject.AutoNew.AutoNew3TEMPLATEPROJECT.AUTONEW.AUTONEW4#TEMPLATEPROJECT.CHECKTEXT.CHECKTEXT5'TEMPLATEPROJECT.PROTECTFORM.PROTECTFORM6/TEMPLATEPROJECT.FORMSSPELLCHECK.FORMSSPELLCHECK79TEMPLATEPROJECT.PROTECTFORM.TOOLSPROTECTUNPROTECTDOCUMENT@@{" @UnknownG* Times New Roman5Symbol3. * Arial;Wingdings5. *aTahoma?= * Courier NewA$BCambria Math"( hGZr4 3QHP?Yo2!xx 'P-09 Medical Certification by PhysicianMedical CertificationP-09Michelle Taylor/Janet Keesler Janet Keesler@         Oh+'0|x 0   , 8 DPX`hp(P-09 Medical Certification by PhysicianMedical Certification Michelle Taylor/Janet KeeslerP-09dQuestions regarding the use of this template should be referred to Janet Keesler at (517) 335-5584.8CS-1835_Non-FMLA_Medical_Certification_by_Physician.dotJanet Keesler7Microsoft Office Word@P@x@~@XKuqGvVT$m$) &" WMFCt l0 O g EMF h@   0 % % Rp@ Arial`3 _m1 tEv1 | v1`3. * ArialCp1Xln1lb2|  dv% % %   T11CAA@!L0 MICHIGAN CIVIL SERVICE COMMISSION            TT21:CAA2@L0 P  Rp@ Arial`3 _m1 tEv1 v1`3. * ArialCp1Xln1lb2 dv% % %   TCDSAACQL0 xDisability Management    TpDSAAQL0 XOffice  TTDSAAQL0 P    TXTcAAXaL0 x400 South Pine Street    TTTcAAaL0 P u   TidsAAiqL0 hP.O. Box 30002    TTdsAAqL0 P a   TPtAAPL0 |Lansing, Michigan 48909  TTtAAL0 P  Rp@ Arial`3 _m1 tEv1 v1`3. * ArialCp1Xln1lb2dv% % %   T`JrAAJL0 TNON$   TTsxAAsL0 P- TlyAAyL0 XFMLA   TxAA2L0 MEDICAL CERTIFICATION BY PHYSICIAN OR PRACTITIONER               TTAAL0 P     '% Ld*/*!??% (      '% Ld!??% (   !*% % %    '% Ld00!??% (    Rp@ Arial4  3 h_m1   HEv1  v1`3. * ArialCp1,ln1@b2Xdv% % %  Tx0hAA0L*\SECTION    TTilAAiL*P d TTmpAAmL*PI TTqtAAqL*P Rp@Symbol4  h 3 h_m1   HEv1  v1`5SymbolCp1,ln1@b2Xdv% % %  TTtAAuL*P% % %  TTAAL*P  TAAL*hAuthorization  TTAAL*Pt TAAL*o Release Medical Information   % % %  TTAAL*P  " '% Ld()(!??%  % Ld()(!??%  % Ld**!??%  % Ld!??%  % Ld!??%  % Ld()(!??%  % Ld!??% !*V % % %  T0o&" WMFC AA0 L*VdI authorize  TTpzAApL*VPm  T{AA{L*V|y (or my minor child s)    T(AAOL*Vattending physician or practitioner to release the information requested below    T`AAL*VTin a TxAAL*V\Section  TTAAL*VP    TT02AA0L*VPI TT35AA3L*VPI TT6:AA6L*VP  T`;JAA;L*VTto  TKAAKL*Vhthe employee s  TTAAL*VP  TAAL*Vtemployer regarding   TAAL*V|my (or my minor child s)    TTAAL*VP  TMAAL*Vphysical or mental condition  TTNQAANL*VP. TXRYAARL*VP  TTZ`AAZL*VPT TaAAaL*Vhis information will only be      T0AA0L*Vlused as necessar TZAA"L*Vy to determine how it will affect     T[AA[L*Vtthe state employee s  TTAAL*VP  TAA"L*Vwork activity in consideration of  T`AAL*VTthe TTAAL*VP  TAA L*Vdrequest for  TXAAL*VPa    T0AA0L*Vlleave of absence T7AAL*V. By signing this release,   T 8AA8NL*VI certify that I am authorized to request the release of this information and    TXAAL*VPI    T0%AA0#L*Vunderstand that I am agre  T%AA# L*V`eing that  T`%AA#L*VTthe TT%AA#L*VP  T%AA#ML*Vemployer may obtain and use such necessary medical information provided below       TT%AA#L*VP    T|0&W5AA03]L*Vabout me (or my minor child), including information relative to HIV or AIDS, if applicable.          TX&5AAX3L*VThis information is retained &" WMFC     T06pEAA0C L*Vdconfidential T`q6~EAAqCL*VTly, TT6EAACL*VP  T6 EAACL*V|consistent with applicab  T`6EAACL*VTle  T6EAACL*Vxcivil service rules,  T 6@EAAC L*Vcollective bargaining agreements  TTA6DEAAACL*VP, TTE6HEAAECL*VP  TdI6aEAAICL*VTand  Tpb6EAAbCL*VXstate  T6EAAC L*V`and federa TX6EAACL*VPl  Td6EAACL*VTlaw.  TT6EAACL*VP  " % Ld()(!??%  % Ld**!??%  % Ld!??%  % Ld()U(!??%  % LdU!??% !*Vu % % %  T0YhAA0fL*VupEmployee s Name    TTYhAAfL*VuP  TXYhAAfL*VuP  TY1hAAfL*VupEmployee s ID No.    TT2Y5hAA2fL*VuP  TT6YhAA6fL*VuP  TTYhAAfL*VuP '% Ldggg!??% ( '% Ld2gg2g!??% (  !*Vu" " % Ld(V)t(V!??%  % LdVtV!??% !*u % % %  T0x~AA0 L*udPatient Name    TTxAAL*uP  TTxAAL*uP  TTxAAL*uP 7 TTxAAL*uP '% Ld7!??% (  !*u" " % Ld(u)(u!??%  % Lduu!??% !* % % %  Tx0XAA0L*\Patient  TTY[AAYL*P  TT\bAA\L*Ps TTcfAAcL*P  TgAAgL*l(or Guardian s)   TAA L*dSignature  TTTAAL*P V TTUXAAUL*P  TlYwAAYL*XDate  TTxAAxL*P p TTAAL*P '% LdXZ!??% ( '% Ldxxp!??% (  !*" " % Ld()(!??%  % Ld!??%    '% Ld*/*!??% (      '% Ld!&" WMFC ??% (   !*% % %    '% Ld00!??% (     T0tAA0 L*`SECTION II    TTuxAAuL*P % % %  TTxAAyL*P% % %  TTAAL*P  TAAL*hCertification  TTAAL*Po TbAAL*tf Medical Condition    TTcjAAcL*Pb TkAAk L*dy Physician   TTAAL*Po TpAAL*Xr Prac  T|AAL*\titioner TTAAL*P  " % Ld()(!??%  % Ld**!??%  % Ld!??%  % Ld()(!??%  % Ld!??% !*Rp@ Arial4  3 h_m1   HEv1  v1`3. * ArialCp1,ln1@b2X dv% % %   TL0AA0UL*This portion is to be filled out by the health care provider to certify the need for  T`AAL*Tthe TT AAL*P  T AA "L*employee s personal medical leave.   TTAAL*P  " % Ld()(!??%  % Ld**!??%  % Ld!??%  % Ld()(!??%  % Ld!??% !*Rp@ Arialh 3 _m1   |Ev1  v1`3. * Arial$Cp1`ln1tb2@dv% % %   TX09AA0L*P1.Rp @ Arialh 3 _m1   |Ev1  ,v1`3. * Arial$Cp1`ln1tb2,Pdv% % %  TT:GAA:L*P % % %  THAAH L*dPatient Name  TTAAL*P  !*" " ! % % %  TXAALP2.% % %  TTAALP % % %  T~AAL|Relationship to Employee  TTAALP  !" " ! % % %  TXAALP3.% % %  TTAALP % % %  TAA LhDate Off Work   TTAALP  !" " !&" WMFC k  % % %  TX&AALP4.% % %  TT'4AA'LP % % %  T5AA5LProbable Return to Work Date  TTAALP  !" " % Ld()(!??%  % Ld**!??%  % Ld!??%  % Ld!??%  % Ld!??%  % Ld!??%  % Ld!??%  % Ld!??%  % Ld!??%  % Ld()(/!??%  % Ld/!??%  % Ld/!??%  % Ld/!??%  % Ld/!??% !*W % % %  TX09AA0L*WP5.% % %  TT:GAA:L*WP % % %  THAAHL*WDescribe the medical facts  TAA L*Wh, including t T AA L*Whe diagnosis and prognosis, TTAAL*WP  TiAAL*Wthat support your certification TTjlAAjL*WP: TTmsAAmL*WP  !*W" " % Ld()(!??%  % Ld**!??%  % Ld!??%  % Ld!??%  % Ld!??%  % Ld!??%  % Ld!??%  % Ld!??%  % Ld!??%  % Ld()V(G!??%  % LdVG!??% !*X % % %  TX0X9fAA0dL*XP6.% % %  TT:XGfAA:dL*XP % % %  THXfAAHdL*XxRegimen of treatment    TXfAAdgL*Xprescribed (indicate number of visits, general nature and duration of treatment, including referral to    !*X"   THguAAHs!L*Xother provider of health services TTguAAsL*XP) TTguAAsL*XP: TTg uAAsL*X&" WMFC K P  !*X" " % Ld(W)W(W!??%  % Ld*WW*W!??%  % LdWWW!??%  % Ld(X)(X@!??%  % LdXX@!??% !* % % %  TX09AA0L*P7.% % %  TT:GAA:L*P % % %  THAAHL*Is inpatient hospitalizatio T AA L*`n required TXAAL*P?  TTAAL*P  TX %AA L*P Rp @Wingdings8 %3 l_m1   LEv1  <v1` ;WingdigsCp10ln1Db2\<`dv% % %  TT&1AA&L*P % % %  TT24AA2L*P  TT57AA5L*P  T|6[AA8L*\Yes % % %  TT\gAA\L*P % % %  TXhmAAhL*P  TXn|AAnL*PNo TT}AA}L*P  !*" " % Ld()(!??%  % Ld**!??%  % Ld!??%  % Ld()(!??%  % Ld!??% !* % % %  TX09AA0L*P8.% % %  TT:GAA:L*P % % %  THAAH;L*If the request is for the employee s medical condition, can   TTAAL*P  T*AAL*the employee perform the    T+aAA+ L*`essential  TaAAb L*hfunctions of  TlAAL*Xtheir TTAAL*P  TAA L*`position?  !*" Rp @ Arial4  3 h_m1   HEv1  \v1`3. * ArialCp1,ln1@b2X\dv% % % % % %  % % %  TTHKAAHL*P( T|L|AALL*\Please a T}AA}L*nswer after discussing with    Td2AAL*Tthe  T3pAA3 L*`employee.) % % %  TTqsAAqL*P  TTtAAtL*P % % %  TTAAL*P % % %  TXAAL*P  T|AAL*\Yes % % %  TTAAL*P % % %  TXAAL*P  TXAAL*PNo%&" WMFC +  % %  TTAAL*P  !*" " % Ld()(!??%  % Ld**!??%  % Ld!??%  % Ld()(!??%  % Ld!??% !* % % %  TX09AA0L*P9.% % %  TT:GAA:L*P % % %  THAAHL*Complete this portion only i  TdAAYL*f the patient is the employee: If the employee cannot perform their position s essential     !*"   TGAAHrL*0functions, explain whether the employee can perform work of any kind and what activities the employee can perform.        TTAAL*P  !*" " % Ld()(!??%  % Ld**!??%  % Ld!??%  % Ld()(<!??%  % Ld<!??% !* J % % %  T`0 @AA0L* JT10.% % %  TTA GAAAL* JP % % %  TH AAH L* JdIf the leave TT AAL* JP  T AAL* Jlis to care for  T AA L* Jdthe patient TX %AAL* JP,  Tx& NAA&L* J\explain TTO RAAOL* JP  TXR ]AASL* JPth Tt^ }AA^1L* Je care the employee will provide and an estimate     T~ AA~L* Jxhow long care will be    !* J"   TxHt&AAH$L* J\needed. TTu{&AAu$L* JP  !* J" " % Ld()(!??%  % Ld**!??%  % Ld!??%  % Ld( )I( A!??%  % Ld I A!??% !*Kw % % %  T`0K@YAA0WL*KwT11.% % %  TTAKGYAAAWL*KwP % % %  THHK6YAAHW*L*KwName of Physician or Practitioner (Please   TT6K:YAA7WL*KwPt Tx:K`YAA;WL*Kw\ype or  TTaKgYAAaWL*KwPp TlhK~YAAhW&" WMFC L*KwXrint) TTKYAAWL*KwP  !*Kw" " !Kw % % %  T`KYAAWLKwT12.% % %  TTKYAAWLKwP % % %  TDKYAAW)LKwType of Practice (Specialization, if any) TTKYAAWLKwP  !Kw" " % Ld(J)J(J!??%  % Ld*JJ*Jj!??%  % LdJJJ!??%  % LdJJJk!??%  % LdJJJ!??%  % Ld(K)v(K,!??%  % LdKvK,!??%  % LdKvK,!??% !*x % % %  T`0x@AA0L*xT13.% % %  TTAxGAAAL*xP % % %  T0HxAAH&L*xSignature of Physician or Practitioner TTx"AAL*xP  !*x" " !x % % %  T`xAALxT14.% % %  TTxAALxP % % %  TdxAALxTDate TTxAALxP  !x" " % Ld(w)w(w!??%  % Ld*ww*wj!??%  % Ldwww!??%  % Ldwwwk!??%  % Ldwww!??%  % Ld(x)(x/!??%  % Ldxx/!??%  % Ldxx/!??% !* % % %  T`0@AA0L*T15.% % %  TTAGAAAL*P % % %  THAAHL*Address of Physician or Practit TlAAL*Xioner TTAAL*P  !*" " ! % % %  T`AALT16.% % %  TTAALP % % %  TAA LdPhone Number  TTAALP  !" " % Ld()(!??%  % Ld**j!??%  % Ld!??%  % Ldk!??%  % Ld!??%  % Ld()(0!??%  % Ld()(!??%  % Ld()(!??%  % Ld**j!??%  % Ld0!??% & WMFC  % Ld!??%  % Ldj!??%  % Ld0!??%  % Ld!??%  % Ld!??% Rp @ Arial`3 _m1 tEv1 |v1`3. * ArialCp1Xln1lb2|dv% % %   TT01AA0L0 P  F(GDIC//WFGDIC!05RRp @ Arial|3 _m1| p`Ev1p| v1`3. * ArialCp1ln1b2  dv% % %   TX:5GBAA:@L05RPCS TTH5KBAAH@L05RP- TdL5cBAAL@L05RT1835 TTd5iBAAd@L05RP    TT:C?PAA:NL05RP2 T`@CNPAA@NL05RT/20 TXOCZPAAONL05RP12 TT[C`PAA[NL05RP  " % % ( 6 60 60666/6/666.6.6   0."System--@ Arial--- =2 @!0 MICHIGAN CIVIL SERVICE COMMISSION             2 @20   @ Arial--- ,2 QC0 Disability Management    2 Q0 Office   2 Q0    +2 aX0 400 South Pine Street      2 a0     2 qi0 P.O. Box 30002     2 q0    .2 P0 Lansing, Michigan 48909   2 0   @ Arial--- 2 J0 NON    2 s0 - 2 y0 FMLA e   V2 20 MEDICAL CERTIFICATION BY PHYSICIAN OR PRACTITIONER                2 0    - @ !*-  - @ !- ,*--- - @ !0- @ Arial--- 2 0*SECTION     2 i*   2 m*I  2 q* @Symbol---  2 u*---  2 *   2 *Authorization   2 *t 72 *o Release Medical Information   ---  2 *  '- @ !(-- @ !(-- @ !*-- @ !-- @ !-- @ !(-- @ !-,V*--- 2 0 *VI authorize   2 p*Vm  /2 {*Vy (or my minor childs)    2 O*Vattending physician or practitioner to release the information requested below    2 *Vin  2 *VSection   2 *V    2 0*VI  2 3*VI  2 6*V  2 ;*Vto   2 K*Vthe employees   2 *V  (2 *Vemployer regarding d  /2 *Vmy (or my minor childs)     2 *V  52 *Vphysical or mental condition   2 N*V. 2 R*V   2 Z*VT 72 a*Vhis information will only be     #2 0*Vused as necessar >2 "*Vy to determine how it will affect     )2 [*Vthe state employees   2 *V  >2 "*Vwork activity in consideration of  2 *Vthe   2 *V  2  *Vrequest for  2 *Va   #2 0*Vleave of absence 52 *V. By signing this release,   2 8N*VI certify that I am authorized to request the release of this information and    2 *VI   12 #0*Vunderstand that I am agree  2 # *Veing that  2 #*Vthe   2 #*V  2 #M*Vemployer may obtain and use such necessary medical information provided below        2 #*V   2 30]*Vabout me (or my minor child), including information relative to HIV or AIDS, if applicable.          72 3X*VThis information is retained    2 C0 *Vconfidential 2 Cq*Vly,   2 C*V  /2 C*Vconsistent with applicab  2 C*Vle  +2 C*Vcivil service rules, c ;2 C *Vcollective bargaining agreements   2 CA*V,  2 CE*V  2 CI*Vand  2 Cb*Vstate  2 C *Vand federa 2 C*Vl  2 C*Vlaw.   2 C*V  '- @ !(-- @ !*-- @ !-- @ !(-- @ !-,uV*--- %2 f0*VuEmployees Name      2 f*Vu  2 f*Vu  %2 f*VuEmployees ID No.     2 f2*Vu   2 f6*Vu   2 f*Vu - @ !g-- @ !g2- ,uV*''- @ !V(-- @ !V-,u*--- 2 0 *uPatient Name     2 *u   2 *u   2 *u 7  2 *u - @ !7- ,u*''- @ !u(-- @ !u-,*--- 2 0*Patient   2 Y*  2 \*s  2 c*  #2 g*(or Guardians)   2  *Signature n   2 * V  2 U*  2 Y*Date n   2 x* p  2 * - @ !Z-- @ !px- ,*''- @ !(-- @ !- - @ !*-  - @ !- ,*--- - @ !0-  2 0 *SECTION II     2 u* ---  2 y*---  2 *   2 *Certification   2 *o )2 *f Medical Condition     2 c*b 2 k *y Physician    2 *o 2 *r Prac  2 *titioner  2 *  '- @ !(-- @ !*-- @ !-- @ !(-- @ !-,*@ Arial--- 2 0U*This portion is to be filled out by the health care provider to certify the need for  2 *the   2 *  >2  "*employees personal medical leave.    2 *  '- @ !(-- @ !*-- @ !-- @ !(-- @ !-,*@ Arial- - -  2 0*1.@ Arial- - -   2 :* - - -  2 H *Patient Name   2 *  ,*'',- - -  2 2.- - -   2  - - -  /2 Relationship to Employee   2   ,'',- - -  2 3.- - -   2  - - -  2  Date Off Work    2   ,'',- - -  2 4.- - -   2 ' - - -  52 5Probable Return to Work Date   2   ,''- @ !(-- @ !*-- @ !-- @ !-- @ !-- @ !-- @ !-- @ !-- @ !-- @ !/(-- @ !/-- @ !/-- @ !/-- @ !/-,W*- - -  2 0*W5.- - -   2 :*W - - -  22 H*WDescribe the medical facts  2  *W, including t 42  *Whe diagnosis and prognosis,  2 *W  :2 *Wthat support your certification  2 j*W:  2 m*W  ,W*''- @ !(-- @ !*-- @ !-- @ !-- @ !-- @ !-- @ !-- @ !-- @ !-- @ !G(-- @ !G-,X*- - -  2 d0*X6.- - -   2 d:*X - - -  +2 dH*XRegimen of treatment    2 dg*Xprescribed (indicate number of visits, general nature and duration of treatment, including referral to    ,X*' =2 sH!*Xother provider of health services.  2 s*X)  2 s*X:  2 s*X  ,X*''- @ !W(-- @ !W*-- @ !W-- @ !@X(-- @ !@X-,*- - -  2 0*7.- - -   2 :* - - -  42 H*Is inpatient hospitalizatio 2  *n required 2 *?   2 *  2  * @Wingdings- - -   2 &* - - -   2 2*   2 5*  2 8*Yes - - -   2 \* - - -  2 h*  2 n*No  2 }*  ,*''- @ !(-- @ !*-- @ !-- @ !(-- @ !-,*- - -  2 0*8.- - -   2 :* - - -  d2 H;*If the request is for the employees medical condition, can    2 *  12 *the employee perform the    2 + *essential  2 b *functions of  2 *their   2 *  2  *position?  ,*'@ Arial- - - - - - - - -   2 H*( 2 L*Please a 52 }*nswer after discussing with    2 *the  2 3 *employee.) - - -   2 q*   2 t* - - -   2 * - - -  2 *  2 *Yes - - -   2 * - - -  2 *  2 *No- - -   2 *  ,*''- @ !(-- @ !*-- @ !-- @ !(-- @ !-,*- - -  2 0*9.- - -   2 :* - - -  52 H*Complete this portion only i  2 Y*f the patient is the employee: If the employee cannot perform their positions essential     ,*' 2 Hr*functions, explain whether the employee can perform work of any kind and what activities the employee can perform.         2 *  ,*''- @ !(-- @ !*-- @ !-- @ !<(-- @ !<-,J *- - -  2 0* J10. - - -   2 A* J - - -  2 H * JIf the leave  2 * J  "2 * Jis to care for  2  * Jthe patientf 2 * J,  2 &* Jexplain   2 O* J  2 S* Jth U2 ^1* Je care the employee will provide and an estimate     ,2 ~* Jhow long care will be    ,J *' 2 $H* Jneeded.   2 $u* J  ,J *''- @ !(-- @ !*-- @ !-- @ !A (-- @ !A -,wK*- - -  2 W0*Kw11. - - -   2 WA*Kw - - -  J2 WH**KwName of Physician or Practitioner (Please    2 W7*Kwt 2 W;*Kwype or   2 Wa*Kwp 2 Wh*Kwrint)r  2 W*Kw  ,wK*'',wK- - -  2 WKw12. - - -   2 WKw - - -  I2 W)KwType of Practice (Specialization, if any)  2 WKw  ,wK''- @ !J(-- @ !jJ*-- @ !J-- @ !kJ-- @ !J-- @ !,K(-- @ !,K-- @ !,K-,x*- - -  2 0*x13. - - -   2 A*x - - -  D2 H&*xSignature of Physician or Practitioner  2 *x  ,x*'',x- - -  2 x14. - - -   2 x - - -  2 xDate  2 x  ,x''- @ !w(-- @ !jw*-- @ !w-- @ !kw-- @ !w-- @ !/x(-- @ !/x-- @ !/x-,*- - -  2 0*15. - - -   2 A* - - -  :2 H*Address of Physician or Practit 2 *ionerr  2 *  ,*'',- - -  2 16. - - -   2  - - -  2  Phone Number   2   ,''- @ !(-- @ !j*-- @ !-- @ !k-- @ !-- @ !0(-- @ !(-- @ !(-- @ !j*-- @ !0-- @ !-- @ !j-- @ !0-- @ !-- @ !-@ Arial- - -   2 00   ,R50@ Arial--- 2 @:05RCS  2 @H05R- 2 @L05R1835  2 @d05R    2 N:05R2 2 N@05R/20  2 NO05R12  2 N[05R  '--  00//..՜.+,0dx   D CS_FormsDeanna HopkinsDepartment of Civil Service  (P-09 Medical Certification by Physician Title  !"#%&'()*+,-./0123456789:;<=>@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~   3 !"#4%&'()*+,-./012J56I89:;<=>?ABCDEFGHKRoot Entry FВ-q 6Data 1Table$4WordDocument*6SummaryInformation(?xDocumentSummaryInformation8Macros:q:qVBA :q:qdirAutoNew __SRP_0; __SRP_1 dR  !"#$%&'()*+,-./0123456789:<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abceghijklmnopqrstuvwyz|}~0* pHdTemplateProjectQH@  = | AS J< 9stdole>stdoleP h%^*\G{00020430-C 0046}#2.0#0#C:\WINDOWS\system32\e2.tlb#OLE Automation0EOfficEOficEE2DF8D04C-5BFA-101B-BDE5EAAC42Egram Files\@CommonMicrosoft Shared\OFFICE14\MSO.DLL#M 10.0 Ob LibraryK׈ThisDocumentGTisDcum7n]* 2 HB1Bx9BE,!r{"B+B CheckTex$E$eYkT"x3" 2 O DM !E FormsSpell"G (FDrCsSp@"lC&B 2 I O)K)tG1Pr5(t&c@I+m 2 O#% m&!fNewXGGt`N`w2I=o * 7*xMEx ((` O`$ .dpAS("  > @` F H B0 .x      (  "0X x   (   (8` p AutoNew Macrodure8 Procedure written 08/02/2000 by Sandra Dailey, MichiganD: Department of Civil Service, Office of Technical Services? DocumentView displays document in page layout view (best fit),B turns off view codes, shows paragraph marks, and shows gridlines.; Added code so user would not be asked if they want to saveA@<( their changes to the document template.&U]@]X &!(.$% $(*.Jrs.$ V!! 9l999Z5(qDock customized command bar.P-09 &%X!P-09 &%Xh9 9qPkH"Returns cursor to top of document. &B@ DBStart @B@Restores window size V! G  V(joAttribute VB_Name = "AutoNew" Sub 4() '0 Macro@Procedure written 08/02/2000 by Sandra Dailey, MichigantDepartment of Civil Service, OffTechn(icas 2P > > < BH P     (8@H X    (  Th DP   x8 Procedure written 8/07/2000 by Sandra Dailey, Office ofT+ Technical Services, Dept. of Civil Servicex7 Procedure checks the formfield result to see if it hasc8 9 numbers and all the characters are numbers. If there5 is nothing in the formfield than user can proceed toP`< next field (user does not have to enter text in this field,I but if user does enter text it has to be numeric and 9 characters long).]@]X]pEmpID &%4!6'. .'0 08d .$:)The employee ID must be "NUMERIC" only. $Please re-enter the ID number using only 9 numeric characters. > EMPLOYEE IDA@< DBEmpID @B@ 0 e6The Employee ID Number must be NO MORE THAN 9 NUMERIC /characters long. Please retype the ID Number, using only "NINE NUMBERS." FEmployee ID Number ErrorA@< DBEmpID @B@M ElseIf iInput >= 1 And iInput < 9 Then 'Or Not IsNumeric(sInput) MsgBox "The Employee ID Number must have 9 NUMERIC " &' "characters. Please retype the ID Number, " &' "using ""NINE NUMBERS.""", vbExclamation, "Employee ID Number Error"> Selection.GoTo What:=wdGoToBookmark, Name:="EmpID"k`kX8PoH@̳Attribute VB_Name = "CheckText" Option Explicit Sub () ' Procedure written 8/07/2000 by Sandra Dailey, Off@ice oftTechnical Servs,@ Dept. Civi hcs the formfield result to see if it has99 numbers all:charact ^. Ifreis nothing in8than user cped@n Lb(doe%IveRen= t,4,a'k!beler$icl9 iloPng). Dim sInpu@t As Sng EiFI%gerMyNN = ActiveDocuRm*.FeFes("EmpID"8).Rh D= Len(#`0 ThenAGoTo F inishElsjNot Is.FL MsgBox " employ@ID must W""NUMERIC"" only" & _"A"Please-eu@ ¨rq.", vbC, "EMPLOYEE T !Sele`on.GWhat:=wdBookmark, :=d'!)G/>K/A&@;&De'NO MORE THAN) u ,W -&*typf) !0us-*7INE BERS."")Exclama)>ErrorAe++x*= 1 An4d \<,'Or W !0 n9! aXE/' "N ., "._.@XW.*.ZE+I [ 2:C  $+3r{#xTxMEH@<6 L*LLLLLL<&@P@(d @@T @XD @p4 P`@$ p0@ pp@ pp@8 pp`P%```@ pp@ V`p`P0@P @p@h @P@ p@ `0@ `@ ``` @`@ `P0PXAS$*\Rffff*0J50e6fc05*\R0*#1*\R0*#17*\R1*#17b*\R1*#c1*\R1*#17e*\R1*#1e*\R1*#a4*\R1*#129*\R1*#c6*\R1*#91*\R1*#c0*\R3*#8c*\R3*#4d*\R3*#4e*\R3*#4f*\R3*#31M " : @P L B 0(X<`@5H h &x 4f    l2hp6f < "  F @  `x < * ( &8 ` p  0    ( 4 HPh p rx   6  X`x  X ` h p  x4 Procedure written 9/30/99 by Sandi Dailey, Michigane ofr: Department of Civil Service, Office of Technical ServicesF Revised 4/22/2002 to customize the button to look like toggle button.cume; Toggles protection for the active document for the "Forms"acro w* menu bar and/or to create a new menu bar.]@1Selecting this option will toggle the protection 7of your active document from "Protect" to "Unprotect," =without resetting the form field results to "zero (no text)." > InformationA@< &   @B@5N P lC@ &Protect FormP-09 V!&%X%Z.J J&Unprotect Form9\ 9^q6Your document has been protected without updating the form fields. > ProtectedA@<dTC@R&Unprotect FormP-09 V!&%X%Z.J J &Protect Form9\ `9^q8Your document has been unprotected. YOU MUST REPROTECT ;YOUR DOCUMENT BEFORE PRINTING OR THE TEXT YOU HAVE ENTERED #IN THE FORM FIELDS WILL BE DELETED. > UnprotectedA@<k@q8o0X? Procedure written by Sandi Dailey 8-13-99 to Protect/Unprotect9 the active document when using the "Tools" dropdown menu toggle selection.]]]6 If the document is not protected, turns protection on# without resetting the form fields. &   @B@5N P Display the Protect Dialog box. $. !' *If Cancel was chosen, exit this procedure. G|j Protect the document. !T lC@ &Protect FormP-09 V!&%X%Z.J J&Unprotect Form9\ 9^q6Your document has been protected without updating the form fields. > L ProtectedA@<d unprotect the document.C@R&Unprotect FormP-09 V!&%X%Z.J J &Protect Form9\ `9^qx  8Your document has been unprotected. YOU MUST REPROTECT ;YOUR DOCUMENT BEFORE PRINTING OR THE TEXT YOU HAVE ENTERED #IN THE FORM FIELDS WILL BE DELETED. > UnprotectedA@<kq.oAttribute VB_Name = "ProtectForm" Option Explicit Sub () ' cedure written 9/30/99 by Sandi Dailey, MichiganlDepartment of Civil Service, O ffTechPnicass`dlg@Dialo gGxAIntegerS f=hnotqed, PturnroPC' bqY=C1_$ o____t@_'DispXlay~  8box{ t =Ts(wdi#"@xЕ.t/'PCa@ncel w`Uchosen, exit30VӖ, pQ0m@-A1l%6qT4 %"ptV,9r,uχu YtntYt t rmz ϟtc.Sttt Xt5t"t +И( uR'6ab2e}"MbD-35?vuctCuWcof?u?u3tttTts "?t?t6?t>tQBNNxothlxvv ThisDocumentn_VBA_PROJECT7OFormsSpellCheck @;PROJECTME (SLSS<N0{00020906-0000-0000-C000-000000000046} "`$ X%hXXAS  " (8@ Px]@ &!(.$ $(*.$o801Attribute VB_Name = "ThisDocument" Bas0{00020P906-0C$0046} |GlobalSpacFalse dCreatablPredeclaIdTru BExposeTemplateDerivBustomizD2Option /licit` P"& Sub _ClA?() D@im obj; As Objec#Set = XActL&.apched *(.SacR*Nothing EndV]ID="{00000000-0000-0000-0000-000000000000}" Document=ThisDocument/&H00000000 Module=CheckText Module=FormsSpellCheck Module=ProtectForm Module=AutoNew HelpFile="" Name="TemplateProject" HelpContextID="0" VersionCompatible32="393222000" CMG="C5C769B6EB7FEF7FEF7AF47AF4" DPB="8A8826F1F60EF60E09F2F70EF849870FD62a  *\G{000204EF-0000-0000-C000-000000000046}#4.1#9#C:\PROGRA~1\COMMON~1\MICROS~1\VBA\VBA7\VBE7.DLL#Visual Basic For Applications*\G{00020905-0000-0000-C000-000000000046}#8.5#0#C:\Program Files\Microsoft Office\Office14\MSWORD.OLB#Microsoft Word 14.0 Object Library*\G{00020430-0000-0000-C000-000000000046}#2.0#0#C:\WINDOWS\system32\stdole2.tlb#OLE Automation(*\G{2DF8D04C-5BFA-101B-BDE5-00AA0044DE52}#2.5#0#C:\Program Files\Common Files\Microsoft Shared\OFFICE14\MSO.DLL#Microsoft Office 10.0 Object Library ASThisDocument0E50e6fbffThisDocumentr{9CheckText0F50e6fbff,CheckText FormsSpellCheck0G50e6fbffHFormsSpellCheck09 ProtectForm0J50e6fc05ProtectFormH%AutoNew0I50e6fbffAutoNew*`=x`H03װ6EU{ f/Lv }th37t[A䠰q j;GJ;9QK8Clq>mjl5 Wordk VBAWin16~Win32Win64xMacVBA6#VBA7# TemplateProjectEstdole`Officeu ThisDocument< _EvaluateDocument_Close7\ objTemplate1ActiveDocument\AttachedTemplateSavedd (CheckTextLtsInputiInput?MyNumbero0 FormFields-|ResulturFinishX IsNumeric$*MsgBoxR vbCritical+} SelectionZWhatCwdGoToBookmarkJ vbExclamation(FormsSpellCheckMyCmdj vbInformationnProtectionTypewdNoProtection Unprotect?Password Application* CommandBars ControlsKCaptionxState msoButtonUp6SpellingCheckedzGrammarCheckedOptionsCheckSpellingAsYouTypejCheckGrammarAsYouTypefSuggestSpellingCorrections+SuggestFromMainDictionaryOnly CheckGrammarWithSpellingShowReadabilityStatisticsIgnoreUppercaseIgnoreMixedDigitsnIgnoreInternetAndFileAddressesShowGrammaticalErrorsDShowSpellingErrorsC Languages wdEnglishUSSpellingDictionaryTypeh wdSpelling6 WholeStory LanguageID CheckGrammar CheckSpellingWEndKey5unitwdStory&ProtectfwdAllowOnlyFormFields!noresetg msoButtonDownJ (ProtectForm'HomeKeyExtend?wdMovez(ToolsProtectUnprotectDocument!dlgDocDialogfxoDialogswdDialogToolsProtectDocument3Displaydocumentpassword R(AutoNew\3ansxt ActiveWindow+ViewI wdPageViewvShowAllITableGridlinesZlShowFieldCodes'Zoom Percentage6VisiblePosition msoBarTopybyezActivate| WindowState|wdWindowStateNormal`ewdWindowStateMaximizeUDocumentjItemzx  I - Z3 xMEx H@@`$ iv`J .dpASA" > @P @ .h x6   0 @ P`hpx   *  0 &@h x  F F8 Pp4   (0 @x8 Procedure written 12/05/2000 by Sandi Dailey, Office ofr9 Technical Services, Michigan Department of Civil Service9 Locks and Unlocks protected form and performs spellcheck( If document is protected, Unprotect it.]@]X&This macro will perform a spell check of the protected form. L SPELL CHECKA@< &!N PT &B@R if us&Unprotect FormP-09 V!&%X%Z.Jrs J &Protect Form9\ `9^qk)Reset document to check for all spelling. &(b &(d f9h9j9l9n9p9r9t9v9xqH &(z &(|  $~(# Set the language for the document. @B@  @( Perform Spelling/Grammar check. f!p &B@dp &B@kX? Moves cursor to bottom of document so it is not in a text box.? Creates error if it trys to reprotect with cursor in text box.  @B@ ReProtect the document. &!N P l &B@ &Protect FormP-09 V!&%X%Z.J J&Unprotect Form9\ 9^qk &!(.$ $(*.$oAttribute VB_Name = "FormsSpellCheck" Option Explicit Sub () ' Procedure written 12/05/2000 by Sandi Dailey, Office of:Technical Servs, Michigan Department- Civi&;@Locks [ Unl protected fper s s%c If docu.is ,& it. Dim objTemplaAs Obj5MyCmd MsgBox "Th1macro will )J aK K "0 & _(:"o`f theMj.", vbInja, "SPELL CHECK܁"qActiveDt.ՁvType <> wdNoG ThLen UnEPassword:="Set C@= ApA&.CommlBars("P-09").Control&G"2With'C.Ca&1%C .Stm= msoBut tonUpGEn\d ACAIARes5Ftoi^ a@qing:@Ӏ= F0alse GraFr >s 5. AsYouBt= Tru  Suggestorr[DsL dFrom@MainDi`LonaryOnly?N 0 howReadability6ist ic IgnoreUp`icasMixed`Digit0CInternetAndF`AddressekDm=c,alError Langua2(wdEnglishUS).%'.d>wdEAql"EYVSelc<.WholeStory#L'%ID5P /Me WVd0A]DEi +cG`|z$Mov;c@ursor zbNo Hso not in text boxA' CresD e!= iftHrys rew `(b,`KKey unit:=`91!Re:7޻=a %A`Allow=XFpieldy70Q:=6__ntP^Nnd__[w_1"o_~ Z_Lc0o_Dowm ;="_Q Pmt@aP{d%c(.SavR_CKNoth b  Q548E475D89465DEDB3FB66DF0FAB39A57C6AC898" GC="4F4DE33C6DC433C533C533" [Host Extender Info] &H00000001={3832D640-CF90-11CF-8E43-00A0C911005A};VBE;&H00000000 [Workspace] ThisDocument=44, 44, 441, 355, CheckText=0, 0, 0, 0, C FormsSpellCheck=66, 66, 463, 377, ProtectForm=88, 88, 485, 399, AutoNew=88, 88, 485, 399, Z ThisDocumentThisDocumentCheckTextCheckTextFormsSpellCheckFormsSpellCheckProtectFormPROJECTwmCompObjrProtectFormAutoNewAutoNew  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q