Personnel Policies and Union Contracts

REQUEST FOR MEDICAL SEPARATION OF EMPLOYEE
(Including Review Of Leave Without Right Of Reinstatement)

INSTRUCTIONS: Departments may copy this form for use. Submit completed form to your Department Human Resources Manager (DHRM) or Employee Relations Consultant (ERC). Please complete the Departmental Medical Separation Checklist to help you with this form.

Note: a copy of the completed Request form will be made available to the employee at the time the medical separation goes forward.

BEFORE COMPLETING THIS FORM, the department must fulfill its obligation to engage in the interactive process with the employee before proceeding further. Have you had a recent discussion with the employee about what possible accommodation(s) the department could provide to enable her/him to return to work? Yes _________(date) If YES, proceed with completing the form. No If NO, please contact the employee immediately and discuss possible accommodation(s) before completing this form.

 

Employee Name:__________________________________________________

Title/TC#:________________________________________________________

Department:______________________________________________________

A. Statement by Department Management Representative. (Attach all documents reviewed)

1. List essential assigned functions that the employee is unable to perform. (Attach job description with essential functions annotated and PEM form)
2. Have you reviewed possible reasonable accommodation with your
   • Department Human Resources Manager Yes No
   • Employee Relations Consultant Yes No
   • Vocational Rehabilitation Counselor Yes No
3. List any accommodations or possible job modifications that were considered.
   1. accommodations offered but not accepted by employee?
   2. accommodations that were attempted and for what duration?
4. Is the employee currently receiving Workers’ Compensation Extended Sick Leave Payments? Yes No
   If yes, do not complete this form. Contact your Vocational Rehabilitation Counselor.
5. Have you notified the employee of this request for review of leave without right of reinstatement and/or medical separation?
   1. Yes orally, _______(date) in writing (if so, attach copy)
   2. No
      If not, do not proceed. Contact employee and advise them you are requesting a review for leave without right of reinstatement and/or medical separation.
6. State the reasons why the employee should be placed on leave without right of reinstatement and/or medically separated.

____________________________________________
Department Management Representative / Date
B. Review by Employee Relations Consultant (Attach all pertinent documents reviewed):

______________________________________________
Employee Relations Consultant / Date
C. Review by Vocational Rehabilitation Counselor (Attach all pertinent documents reviewed):

______________________________________________
Vocational Rehabilitation Counselor / Date

cc: Vocational Rehabilitation Counselor
Department Management Representative
Employee Relations Consultant