Ridgeland Federation of Teachers Local 943

Sick Leave Bank

Physician Documentation Form
--------------------------------------------------------------------------------------------------------------------Ridgeland Public School District 122
6500 West 95th Street
Oak Lawn, IL 60453
Phone: (708) 599-5550
Fax: (708) 599-5626
--------------------------------------------------------------------------------------------------------------------***************************CONFIDENTIAL***************************
TO THE PHYSICIAN:
Regulations of the Sick Leave Bank of Ridgeland School District #122 provide that a fully
completed Physician Documentation Form be submitted PRIOR to granting any request for
benefits.
I request that the following medical statement be completed by my physician in order to be
submitted to the Sick Leave Bank committee of Ridgeland School District #122.
___________________________________________________ ________________________
Signature of District #122 Employee
Date
--------------------------------------------------------------------------------------------------------------------The following form must be completed by the treating physician:
1. This is to certify that _____________________________________________________
(Full Name of Patient)
has been under my professional care since _________________________ (date) and that
I have diagnosed his/her present condition as follows:
2. Official diagnosis in full (attach additional pages if necessary): _____________________
________________________________________________________________________
________________________________________________________________________
3. Can this procedure, surgery, or treatment be safely deferred until a natural/planned break
in the school calendar? Check one: ______ Yes ______ No
4. Is this procedure elective or cosmetic in nature? Check one: ______ Yes ______ No
5. Anticipated date of procedure, surgery, or treatment: _____________________________
6. Please state the anticipated duration of the absence:
________________________________________________________________________
7. What is the extent and nature of physical activity allowed during the illness or recovery
period of your patient?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

8. Please state the anticipated date of return to work: _______________________________

9. Please note any restrictions or limitations your patient may have upon returning to work:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
10. Additional Comments:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Physician Information:
Physicians Printed Name: ________________________________________________________
Address: ______________________________________________________________________
City: ______________________________________ State: ____________ Zip: ____________
Telephone: ________________________________________

Please note: Any fraudulent information given to the Sick Leave Bank shall result in the
member having to repay the fraudulently obtained days, their permanent exclusion from
membership in the Sick Leave Bank, and possible disciplinary action by the district.

My signature below denotes that the patient discussed above is under my direct care and
that all information provided on this form is true and accurate.

Physicians Signature: _______________________________________ Date: _____________