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    Medical and Maternity Leave Form

    Uploaded by

    Rome Dela Cruz
    This document is a medical/maternity leave request form that requires the employee to provide their personal details such as name, contact information, expected dates of leave, and medical reason for leave. It outlines the process for securing approval and necessary documentation, including fit-to-work certifications. It reminds employees that clinic staff may check on their condition and location while on leave, and consequences for failing to submit proper documentation to return to work.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Medical and Maternity Leave Form

    Uploaded by

    Rome Dela Cruz
    48 views1 page
    This document is a medical/maternity leave request form that requires the employee to provide their personal details such as name, contact information, expected dates of leave, and medical reason for leave. It outlines the process for securing approval and necessary documentation, including fit-to-work certifications. It reminds employees that clinic staff may check on their condition and location while on leave, and consequences for failing to submit proper documentation to return to work.

    Original Description:

    Medical leave form

    Original Title

    MEDICAL AND MATERNITY LEAVE FORM

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    This document is a medical/maternity leave request form that requires the employee to provide their personal details such as name, contact information, expected dates of leave, and medical reason for leave. It outlines the process for securing approval and necessary documentation, including fit-to-work certifications. It reminds employees that clinic staff may check on their condition and location while on leave, and consequences for failing to submit proper documentation to return to work.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    48 views1 page

    Medical and Maternity Leave Form

    Uploaded by

    Rome Dela Cruz
    This document is a medical/maternity leave request form that requires the employee to provide their personal details such as name, contact information, expected dates of leave, and medical reason for leave. It outlines the process for securing approval and necessary documentation, including fit-to-work certifications. It reminds employees that clinic staff may check on their condition and location while on leave, and consequences for failing to submit proper documentation to return to work.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Medical / Maternity Leave Request Form

    Please complete data below. Only those with COMPLETE INFORMATION will be processed:

    EMPLOYEE NAME:_____________________________________________________ Date filed:___________________

    HR ID No.: __________________ DEPARTMENT/PROGRAM/LOB: __________________________________________

    Address while on leave: _________________________________________________________________________________

    Permanent Address: ____________________________________________________________________________________

    Contact number/s: (1)___________________________ (2)_______________________________

    Person to notify in case of emergency:______________________ Relationship______________ Contact no.: _____________

    I certify that my contact details are true and correct and I am willing to bear all the legal responsibilities arising therefrom.
    Signed: __________________________

    (To be filled out by Clinic Staff)


    Reason for prolonged leave :  Medical /  Maternity:

     Medical condition due to: ____________________________________________________________________________

     Maternity leave (AOG in weeks): _________________________ Expected date of delivery: _______________________

    At (hospital/clinic) ______________________________________________________________________________

     Supporting documents: ______________________________________________________________________________

    Covered period of leave: From _____________________________ to _____________________________ ( ________ days )

    Back to work date: ____________________________________

    IMPORTANT REMINDERS: (Please read then sign before each number.)


    1. This is a leave request that is subject to the approval of the Company Physician. You are hereby instructed to make a
    follow through if your leave request has been approved. You may call (02) 899-2200 loc. (VXI Clinic).

    2. While on leave, PLEASE BE INFORMED THAT CLINIC PERSONNEL MAY VISIT YOU, CALL YOU AND CHECK WITH
    THE HMO PROVIDER to verify your health condition. You MUST be in your declared address while on leave.

    3. You are required to secure a FIT TO WORK certification from your HMO accredited attending physician or fit to work
    clearance from the Company Physician and personally submit this to Clinic not later than one (1) day before your
    expected back to work date.

    4. If there is a need for you to go on extended leave, you are required to see your HMO accredited attending physician or our
    Company Physician for re-evaluation and personally submit a medical certificate (stating the justification for leave
    extension) to the Clinic one (1) day prior to your expected back to work date. It is mandatory to see the Company
    Physician if you are to extend your leave more than once.

    5. Failure to personally submit a fit to work medical certificate to the Clinic one (1) day before your expected back to work date,
    YOUR DATE OF BACK TO WORK will be counted against your attendance compliance and subject for corresponding
    sanction under existing company rules.

    6. This form will be endorsed to SITE HR on ________________________ should you fail to submit a medical certificate one
    (1) day before your expected back to work date and subject for corresponding sanction under existing company rules.

    ADDITIONAL REMINDERS FOR MATERNITY LEAVE: (Please read then sign before each number.)
    7. Those on maternity leave are to complete 105 calendar days for live childbirth, 60 days for miscarriage and 120 days for live
    childbirth regardless of delivery type for solo parents with updated/current Solo Parent ID.
    8. For live childbirth, if you wish to extend leave for another 30 days without pay, you will notify HR, submit letter of intent at
    least 45 days before the end of your maternity leave.

    ***I have read the conditions above and I will abide by these conditions:***

    ______________________________________________ ____________________________________________
    EMPLOYEE’s signature over printed name/date or Authorized representative’s name/signature/date

    Noted by (Supervisor’s printed name/signature/date): _______________________________________________________

    Clinic Staff’s name/signature/date: __________________________________________________________________________

    Approved by (Company Physician’s name/signature/date): _____________________________________________________


    VXI Clinic 010 revised August 2019

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