Abraham Baldwin Agricultural College

Physician’s Certification of Emergency or Life-Threatening Medical Condition

        Shared Leave 

Page 1 to be completed by employee:

Statement from Abraham Baldwin Agricultural College employee to the licensed physician:

I am applying for leave through the Abraham Baldwin Agricultural College (ABAC) shared leave program due to my illness or injury.  ABAC’s shared leave program allows employees affected by emergency or life-threatening medical conditions (defined as conditions involving a serious, extreme, or life-threatening illness, injury, impairment or condition) and who also meet other specified criteria, to receive leave donated by other employees.  A committee of ABAC employees will review my application to determine if my request meets the criteria for approval.  Your certification of my medical condition is crucial in making that determination.  Your response to each question on the attached page will be greatly appreciated.  I authorize any licensed medical practitioner who examines me to release any information or facts concerning my condition to:  Abraham Baldwin Agricultural College, Office of Human Resources; the Shared Leave Certification Committee; and to other appropriate ABAC officials.

For the purposes of this program, “life-threatening or emergency medical condition” means a health condition involving a serious, extreme, or life-threatening illness, injury, impairment, or condition that is likely to require my absence from duty for a period of time longer than the amount of sick leave and annual leave available to me, and the health condition is such that it is not medically appropriate for me to delay the absence in order to accrue additional sick or annual leave prior to the absence.  The absence may be continuous, as in hospitalization following surgery or an accident, or the absence may be intermittent, as in periodic absences for chemotherapy or other procedures.

I understand any medical information forwarded to the Shared Leave Committee will remain confidential and will not be shared with other employees in Human Resources, my department, or elsewhere within the College. 

___________________________________________________________          _______________________________________

Name of employee         (please print)                                         Social Security Number

___________________________________________________________          _______________________________________

Signature of employee                                                                Date

(Or the printed name and signature of the person having documented

power of attorney for the named employee.  Attach documentation of

power of attorney.)

Revised April 2004

Abraham Baldwin Agricultural College

Shared Leave

Page 2 to be completed by physician:

The following individual has requested a Certification of Emergency or Life-Threatening Medical Condition:

_________________________________________________________________________________________________________

Name of ABAC employee

_____________________________________________________                  __________________________________________

Name of licensed physician (please print)                                                                              Physician’s phone number

_________________________________________________________________________________________________________

Name of medical practice (if applicable)

_________________________________________________________________________________________________________

Physician’s mailing address

Please initial ALL the following that are true of this individual:

______  This individual is affected by a serious, extreme, or life-threatening illness, injury, impairment, or condition.

______  It is not medically appropriate for this individual to delay the necessary treatment, therapy, recuperation, or other medical intervention until some later date.

______  This individual’s medical condition or the necessary treatment, therapy, recuperation, or other medical intervention will require this individual to be absent from work as indicated below:  (Complete and initial an estimate of the individual’s expected absence):

______  This individual will not be able to return to work at all during ____________________OR

                                                                                                                            (dates)

______  This individual will be able to work only approximately _________ hours per week during _________________ OR   
(dates)

______  This individual will not be able to work at all during __________________________ AND

                                                                                                                        (dates)

this individual will be able to work only approximately __________ hours per week during _____________________________.

                                         (dates)

___________________________________                            _______________________________________

Signature of physician                                                                                     Date

After completing this form, please return it to the ABAC employee for whom certification is requested (or to the individual holding power of attorney for the employee) so s/he may submit it to the institution’s Shared Leave Certification Committee.  Thank you for your assistance in this process.