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Forms

Forms

Extended Illness Absence Card (SEH-3)

Extended Illness Absence Card (Form SEH-3)

Form SEH-3 must be completed by the employee and his/her doctor any time an employee takes more than three consecutive sick days.

One card must be submitted for each pay period during which an absence falls. (See the school district's pay schedule below to be sure you are entering the correct dates on the SEH-3 card.)

  • REQUEST FOR EXTENDED PERSONAL ILLNESS-FORM SEH-3.

Note: If you print the form from this web site, you must mail it in a separate envelope to the following address:

School District of Philadelphia
Employee Health Services-Suite 134
440 N. Broad. St.
Philadelphia, PA   19130

School Personnel Health Record

All School District employees must have current health records on file with EHS. If you are about to go through the pre-employment process, or if you need to update your record with our office, please have your doctor complete the following:

School District Personnel Health Record

 Please Note: To meet the legal requirements of the Commonwealth of Pennsylvania, your tuberculosis/PPD results must be read within a 48-72 hour window of the date applied. Be sure your healthcare provider fills in this section of the form completely and accurately, and that he/she signs next to the results of the PPD skin test.

If you do not have a personal physician, see the link below for a list of local clinics in Philadelphia.

Family & Medical Leave Act of 1993 (FMLA)

 

The following are Department of Labor postings about the FMLA that you should review:

EMPLOYEE RIGHTS UNDER THE FMLA

MILITARY FAMILY LEAVE 

Please submit a completed SDP FMLA cover sheet for a determination of your FMLA eligibility. If you are eligible, you will receive a FMLA Eligibility Notice and the appropriate FMLA certification for completion. After the submission of your completed FMLA certification, a determination of the designation of your leave as FMLA protected will be made and you will then receive a FMLA Designation Notice. 

The completed SDP FMLA cover sheet can be sent via: FAX: (215) 400-4661; EMAIL: fmla@philasd.org or MAIL: 440 N Broad St, Ste 134, Phila., PA 19130 

SDP FMLA COVER SHEET

*If you are requesting FMLA protection for leave to care for a child age 18 and older, please review the following Department of Labor fact sheet for additional information: 

FMLA COVERAGE FOR ADULT CHILD

 

Below are the FMLA certification forms for your convenience. However we ask that you submit the FMLA certification after you have been notified of your FMLA eligibility.

FMLA CERTIFICATION FOR PERSONAL ILLNESS

FMLA CERTIFICATION FOR ILLNESS OF FAMILY MEMBER

 

REASONABLE SUSPICION FORM

Reasonable Suspicion Form

Employee Health Services Contact form

 

If you have any questions or need assistance, please complete the following form and we will get back to you as soon as possible.

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