Application For Leave Of Absence Due To Illness Form
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1
2NEW YORK CITY TRANSIT
MANHATTAN and BRONX SURFACE TRANSIT OPERATING AUTHORITY
TO BE PREPARED IN
DUPLICATE
SEVENTY-FIVE PERCENT (75%) SUPPLEMENT PAY
Division _______________________
Department _______________________ Date ____________ 20
I, __________________________ Title ____________________ Pass No. _______________________
Rate ___________________ Pay Location _____________________hereby apply for leave of absence from duty, with
75
% pay, on account of illness or injury (from causes other than accident while on duty) in accordance with statement below:
I also may receive the additional 25% for a total of 100% of my pay if I have more than 50% of my sick leave balance
available at the onset of this illness.
Absent from ____________________, 20____, ________ A.M. P.M. to __________, 20____, _____________ A.M. P.M. inclusive
If absence is due to a non-service accident, state where, when, and how accident occurred.
I was unable to work during said period because ___________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Did accident occur while working for employer other than T.A.?
_____________ Yes/No
Did this disability arise as a result of a Service-Connected Illness? _____________ Yes/No
___________________________________
(signature)
_______________________________________________________________________________________
(This certification must be completely filled out by the attending physician before payment for sick leave at 75% pay will be passed
upon.)
DOCTOR’S CERTIFICATION
Patient’s Name _____________________________________________________ Age ________________ Sex _______________
first
middle
last
I hereby certify that the above named employee was treated by me on the dates and for the illness noted below:
1)
Diagnosis ________________________________________________________________________________________
________________________________________________________________________________________
Patients Symtoms/ _________________________________________________________________________________
Objective Findings __________________________________________________________________________________
__________________________________________________________________________________
2) Treatment:
_________________________________________________________________________________
__________________________________________________________________________________
3)
Dates of Treament: Home____________ Office______________________ (Hospital)________________________
I further certify that this illness so incapicitated this employee that he was unable to perform his duties during the following
period:
From ___________________________________
To _____________________________________________
I make this certification knowing that the above mentioned employee will use it as the basis of an application for sick leave with 75%
pay.
Date _________________________________
Signature ____________________________________ M.D.
_____
Address
_________________________________
________
Tel. No.
___________________________
(OVER)
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