THE PENNSYLVANIA STATE UNIVERSITY
James M. Elliott Building
University Park, PA 16802

SICKNESS AND ACCIDENT SUPPLEMENT (SAS) CLAIM FORM

SECTION 1:  TO BE COMPLETED BY EMPLOYEE - PLEASE PRINT

1. ________________           __________________      __________     _____
        Employee Name              PSU ID NUMBER            Date of Birth      Sex
   
   
   

2. College or Department:________________________________
   
   

3. Is this claim the result of a work-related illness or injury? ______Yes     _____No
   If yes, furnish details: ______________________________________________ ______________________________________________________________
   
   
   

4. What is the nature of your illness or injury: ______________________________ ______________________________________________________________
   
   

5. Date of injury or beginning of illness:___________________________________ ______________________________________________________________
   
   

6. How long do you expect the disability to continue: ________________________ ______________________________________________________________
   
   

7. Are you covered by another sickness and accident plan?   ______Yes    _____No
   If yes, furnish name and address of company:_____________________________
   
   

8. Have you filed for:                           Yes                          No
      Social Security                           ______                     _______
      Worker's Compensation            ______                     _______
       Disability Retirement Benefits    ______                     _______
   
   

9. Date(s) and name(s) and hospital(s) providing treatment
   

   Date	Physician	Hospital

   
   I hereby certify that the above statements are correct and I authorize the release of information from the above named physician(s) and hospital(s).

   _____________________   ____________________________   __________
    Employee's Signature                        Home Address                               Date
   
   
   SECTION 2:  TO BE COMPLETED BY ATTENDING PHYSICIAN
   
   Patient's Name:__________________________________________________
   
   Diagnosis and concurrent condition:___________________________________
   

   ---

   Is condition due to injury arising out of patient's employment?   ___ Yes    ___No
   
   Report of service:
   
   

   Dates of Service	Place of Service	Description of Surgical or Medical Services Rendered

   
   Is employee expected to return to work?  If so, approximate date:  ____________
   
   ______________________________________________
   Physician's Signature
   ___________________________     _________________    ______________
   Physician's Name (print)                           Degree                              Date
   
   ________________________     _______________    ____        ________
   Street Address                                      City                    State          Zip Code
   
   SECTION 3:  TO BE COMPLETED BY EMPLOYEE'S HUMAN RESOURCES REPRESENTATIVE OR DIRECTOR OF BUSINESS SERVICES
   
   Has employee used more than six (6) sick days of accumulated sick leave without doctor's certification in the twelve (12) month period immediately preceding the absence?                    _________Yes               __________No
   
   Normal days off _________    ____________
   
   _________________________________           _______________________
        Name of HRR/DOBS                                                Phone Number
   
   _____________________________         _____________________________
   Date employee's absence commenced         Employee's hourly rate
   
   ______________________________
   Last day employee received full pay
   

   Please include a copy of Employee's Vacation/Sick Leave Record(s)

   COMPLETED FORM MUST BE RETURNED TO
   EMPLOYEE BENEFITS DIVISION
   JAMES M. ELLIOTT BUILDING, UNIVERSITY PARK, PA 16802