**Sandia National Laboratories**

**INSTRUCTIONS FOR COMPLETING PHYSICIAN'S CERTIFICATE OF ILLNESS/INJURY
(PCII)**

Effective January 1, 2009.

INSTRUCTIONS TO MANAGER:

  ---------------- ------------------------------- --- ---------------------------------
  1\.              The immediate **manager** of an     In the event of scheduled surgery
                   employee who has been absent        or other scheduled treatment, the
                   due to illness or injury for        manager may provide the employee
                   two (2) consecutive calendar        with this form in advance of the
                   days, and anticipates the           anticipated absence.
                   absence could meet criteria in      
                   #2 below, should complete the       
                   top portion of the Physician's      
                   Certificate of Illness/Injury       
                   (PCII) \[SF 4560-G (12/08)\]        
                   provide it to the employee by       
                   the third day of absence.           

                                                       

  **INSTRUCTIONS                                       
  TO EMPLOYEE:**                                       

  Sickness absence                                     
  benefits provide                                     
  for temporary                                        
  leave for                                            
  diagnosed                                            
  medical                                              
  conditions with                                      
  a goal of                                            
  assisting                                            
  employees in                                         
  successfully                                         
  returning to                                         
  work. To qualify                                     
  for paid                                             
  sickness absence                                     
  benefits, please                                     
  follow these                                         
  instructions.                                        
  Failure to                                           
  comply may                                           
  result in denial                                     
  of sickness                                          
  absence                                              
  benefits. Note:                                      
  in this form,                                        
  HBE refers to                                        
  the Health,                                          
  Benefits, and                                        
  Employee                                             
  Services Center                                      
  (in NM) or to                                        
  the HBE                                              
  Department (in                                       
  CA.)                                                 
  ---------------- ------------------------------- --- ---------------------------------

+---+------------------------------+---+---------------------------------+
| 1 | **You must ensure that the   | 5 | **You do not have to bring this |
| \ | top portion of this form is  | \ | completed certificate with you  |
| . | completed including signing  | . | in order to return to work.**   |
|   | the authorization for        |   | The physician or health care    |
| 2 | release of information.**    | 6 | practitioner can fax the PCII   |
| \ | This authorization grants    | \ | to (505) 845-1046 (SNL/NM),     |
| . | permission to your health    | . | (925) 294-2392 (SNL/CA) or mail |
|   | care provider to provide     |   | it to the HBE.                  |
| 3 | supportive medical           | 7 |                                 |
| \ | information for this absence | \ | You are responsible for         |
| . | [only]{.underline} and will  | . | returning to work by the date   |
|   | be used to determine         |   | specified on the PCII and       |
| 4 | eligibility for sickness     | 8 | approved by the HBE or          |
| \ | absence benefits.            | \ | submitting a new or modified    |
| . |                              | . | PCII (or other acceptable       |
|   | **You must be seen by your   |   | medical documentation) before   |
|   | personal physician or an     | 9 | the original approved           |
|   | Urgent Care facility**       | \ | return-to-work date has         |
|   | **within the first five      | . | expired.                        |
|   | consecutive workdays or      |   |                                 |
|   | seven consecutive calendar   | 1 | **You must return to work       |
|   | days of absence.** If your   | 0 | through the HBE Clinic if       |
|   | absence meets the above      | \ | you:**                          |
|   | criteria, you must have your | . |                                 |
|   | physician complete this form |   | \(1\) were hospitalized; (2)    |
|   | certifying that you were     | 1 | underwent a surgical procedure; |
|   | under his/her care and       | 1 | (3) were absent because of a    |
|   | unable to work because of    | \ | work-related illness or injury; |
|   | illness or injury. During    | . | (4) were absent due to heart or |
|   | lengthy absences, you may be |   | psychiatric conditions; (5)     |
|   | required to submit           |   | wear a dosimeter and have       |
|   | additional PCII's or medical |   | undergone a nuclear medicine    |
|   | documentation to support the |   | procedure; (6) were evaluated   |
|   | absence, be requested to     |   | by an outside facility for a    |
|   | sign a release for medical   |   | potential exposure; (7) were    |
|   | information, or be requested |   | absent more than 40 hours in    |
|   | to report to the HBE Clinic. |   | one month; (8) were absent as a |
|   | For SNL/CA employees who are |   | result of any injury or         |
|   | eligible to file a State     |   | treatment that might effect     |
|   | Disability Insurance (SDI)   |   | your job performance; (9) were  |
|   | claim, the "Doctor's         |   | requested by your manager to do |
|   | Certificate" (page 3) of the |   | so; (10) were requested by the  |
|   | State Claim form (DE2501)    |   | HBE to do so; or (11) you were  |
|   | will be accepted in lieu of  |   | absent five consecutive         |
|   | a PCII.                      |   | workdays or seven consecutive   |
|   |                              |   | calendar days.                  |
|   | **The PCII must be received  |   |                                 |
|   | in the HBE within 14         |   | NM and CA Sites: Telephonic     |
|   | calendar days of the first   |   | return to work (RTW) will be    |
|   | date of absence.** HBE       |   | done for employee's RTW after   |
|   | and/or the employee's        |   | child birth, or employee's      |
|   | manager may require a PCII   |   | working in remote sites.        |
|   | for absences of shorter      |   |                                 |
|   | duration than five           |   | **You must obtain the approval  |
|   | consecutive workdays or      |   | of the HBE before you: a) leave |
|   | seven consecutive calendar   |   | town during sickness (for any   |
|   | days when in their opinion   |   | reason), including medical      |
|   | circumstances warrant.       |   | treatment and/or testing, or b) |
|   |                              |   | start a scheduled vacation      |
|   | The PCII must be acceptable  |   | immediately following sickness  |
|   | to HBE or sickness absence   |   | absence. Routine medical visits |
|   | benefit time may be denied.  |   | or treatments between           |
|   | The diagnosis and treatment  |   | neighboring cities do not       |
|   | of the physician or health   |   | require HBE approval.**         |
|   | care practitioner completing |   |                                 |
|   | this form must be within the |   | It is your responsibility to    |
|   | scope of their practice and  |   | discuss the return to work date |
|   | should normally be completed |   |                                 |
|   | by a Doctor of Medicine      |   | (as stated on the attached      |
|   | (MD), or Doctor of           |   | certificate) with your treating |
|   | Osteopathy (DO). All         |   | physician or health care        |
|   | absences must fall within    |   | practitioner and your           |
|   | the official disability      |   | **manager**.                    |
|   | guidelines. PCII's are       |   |                                 |
|   | accepted from other health   |   | DOE Order 472.1c requires that  |
|   | care practitioners only in   |   | DOE clearance access            |
|   | the following limited        |   | authorizations "be terminated   |
|   | situations:                  |   | when an individual is on leave  |
|   |                              |   | of absence or on extended leave |
|   | a\. Chiropractors: Accepted  |   | and will not require access for |
|   | only for spinal-muscular     |   | at least 90 days." (Note: this  |
|   | problems                     |   | includes 90 consecutive         |
|   |                              |   | calendar days of sickness       |
|   | with signs and symptoms      |   | absence). Prior to the          |
|   | directly in the back. They   |   | employee's expected return to   |
|   | are not                      |   | work, the badge office must be  |
|   |                              |   | notified by the Manager to      |
|   | accepted for other health    |   | request clearance access        |
|   | problems, the signs and      |   | reinstatement. If reinstatement |
|   | symptoms                     |   | is not completed prior to the   |
|   |                              |   | employee's return, she/he will  |
|   | of which are in other parts  |   | receive an uncleared access     |
|   | of the body, whether or not  |   | badge and be escorted until the |
|   |                              |   | reinstatement is complete.      |
|   | attributed to the back by    |   |                                 |
|   | the practitioner.            |   | Absences associated with paid   |
|   |                              |   | and approved sickness absence   |
|   | b\. Dentists: Absence        |   | benefits meet the requirements  |
|   | involving dental care or     |   | of the Family and Medical Leave |
|   | treatment                    |   | Act (FMLA) for personal         |
|   |                              |   | sickness. **If you are eligible |
|   | which temporarily prohibits  |   | under the FMLA this absence     |
|   | you from working. Routine    |   | will count towards your FMLA    |
|   |                              |   | entitlement.** Refer to site:   |
|   | visits for fillings,         |   | [[http://www                    |
|   | cleaning, minor extractions  |   | .sandia.gov/benefits/spd/pdfs/F |
|   | or other                     |   | MLA_Fact_Sheet.pdf]{.underline} |
|   |                              |   | ](http://www.sandia.gov/benefit |
|   | treatment of similar nature  |   | s/spd/pdfs/FMLA_Fact_Sheet.pdf) |
|   | are not considered an        |   | Questions and/or information    |
|   | illness or                   |   | regarding ---call the HBE       |
|   |                              |   | Customer Service, 844-4237.     |
|   | injury.                      |   |                                 |
|   |                              |   | In California, call Health,     |
|   | c\. Podiatrists: Accepted    |   | Benefits, and Employee Services |
|   | only when treatment is       |   | Department 8527 (MS 9112),      |
|   |                              |   | 294-2700.                       |
|   | appropriate for the illness  |   |                                 |
|   | or injury.                   |   |                                 |
|   |                              |   |                                 |
|   | d\. Certified Nurse          |   |                                 |
|   | Practitioner and Physicians' |   |                                 |
|   | Assistant: are accepted only |   |                                 |
|   | when the treatment is        |   |                                 |
|   | appropriate for the illness  |   |                                 |
|   | or injury.                   |   |                                 |
|   |                              |   |                                 |
|   | e\. Certified Nurse          |   |                                 |
|   | Midwives: For any absence    |   |                                 |
|   | involving normal/            |   |                                 |
|   | uncomplicated obstetrics and |   |                                 |
|   | delivery.                    |   |                                 |
|   |                              |   |                                 |
|   | f\. Licensed Mental Health   |   |                                 |
|   | Professional (e.g.           |   |                                 |
|   | Psychiatrist, Licensed       |   |                                 |
|   | Psychologist, Licensed       |   |                                 |
|   | Professional Counselor). For |   |                                 |
|   | any absence associated with  |   |                                 |
|   | behavioral health diagnosis. |   |                                 |
+---+------------------------------+---+---------------------------------+

**Sandia National Laboratories**

**PHYSICIAN'S CERTIFICATE OF ILLNESS/INJURY (PCII)**

  -----------------------------------------------------------------------
  THIS PORTION COMPLETED BY **EMPLOYEE/ EMPLOYEE'S ORGANIZATION**

  -----------------------------------------------------------------------

+--------+--------+-----------+--------------------------+-------------+
| Date   |        | E         |                          | First Day   |
| Orig   |        | mployee's |                          | of Absence  |
| inated |        | Name      |                          |             |
|        |        |           |                          | **     **   |
| **     |        |           |                          |             |
|     ** |        |           |                          |             |
+--------+--------+-----------+--------------------------+-------------+
| SNL ID |        | Address   |                          | Home & Work |
| No.    |        | (Street,  |                          | Phone       |
|        |        | City, and |                          | No.         |
|        |        | State)    |                          |             |
|        |        |           |                          |             |
|        |        |           |                          |             |
+--------+--------+-----------+--------------------------+-------------+
| Org.   | Mail   | Date of   | Manager's Name and Phone | Represented |
| /Bldg. | Stop   | Birth     | No.                      |             |
| No.    |        |           |                          | Yes No      |
|        |        |           |                          |             |
|        |        |           |                          |             |
+--------+--------+-----------+--------------------------+-------------+
| Was    |        |           | What was the cause of    |             |
| this   |        |           | that accident? Briefly   |             |
| il     |        |           | describe. (e.g. MVA,     |             |
| lness/ |        |           | fall, fire, etc.)        |             |
| injury |        |           |                          |             |
| the    |        |           |                          |             |
| result |        |           |                          |             |
| of an  |        |           |                          |             |
| acc    |        |           |                          |             |
| ident? |        |           |                          |             |
|        |        |           |                          |             |
| Yes No |        |           |                          |             |
+--------+--------+-----------+--------------------------+-------------+

**Authorization for Release of Information (Signature is required)**

I authorize any physician, medical practitioner, health care
practitioner, hospital, Veterans Administration hospital, clinic, other
medical or medically related facility having information as to
diagnosis, treatment, and prognosis with respect to any physical or
mental condition, and/or treatment of me related to this absence/illness
**only**, to provide Sandia National Laboratories' Health Benefits and
Employee Services any and all such information.

I understand that the information obtained by use of this Authorization
will be used by Sandia National Laboratories' Health Benefits and
Employee Services to determine eligibility for benefits. I understand
that I have the right to revoke this authorization in writing at any
time. This authorization will expire on
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ or one year from date of
signature.

**Employee's Signature**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date
\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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<tbody>
<tr class="odd">
<td colspan="18">THIS PORTION COMPLETED BY <strong>EMPLOYEE’S
PHYSICIAN</strong></td>
</tr>
<tr class="even">
<td colspan="4"><p><strong>TO</strong></p>
<p><strong>PHYSICIAN</strong></p></td>
<td colspan="14">Sickness absence benefits provide temporary leave for
diagnosed medical conditions, with a goal of assisting employees in
successfully returning to work. An employee must be considered unable to
work because of sickness or injury, as certified by the employee’s
physician, <strong>before</strong> sickness benefits can be paid to the
employee. If the employee’s absence attributed to sickness is not
approved sickness benefit time may be denied. During lengthy absences,
additional Physician’s Certificates or medical treatment records may be
requested. If you have any questions, please contact the Health Benefits
and Employee Services at 844-4237 (SNL/NM) or 294-2700 (SNL/CA).
<strong>Please keep a copy for your patient medical
records.</strong></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="5">Thank you for your cooperation.</td>
<td colspan="9">Rick Sauerman, M.D., Medical Director</td>
</tr>
<tr class="even">
<td colspan="4"><p><strong>TREATMENT</strong></p>
<p><strong>DATES</strong></p></td>
<td colspan="6">Date <strong>First</strong> Seen During This
Absence</td>
<td colspan="8">Date <strong>Last</strong> Seen During This Absence</td>
</tr>
<tr class="odd">
<td colspan="4"><strong>DIAGNOSIS</strong></td>
<td colspan="12">(Include complications if any)</td>
<td colspan="2"><strong>ICD9 Code</strong></td>
</tr>
<tr class="even">
<td colspan="4"><h1 id="surgery">SURGERY</h1></td>
<td colspan="2">Date</td>
<td colspan="12">Type of Surgery</td>
</tr>
<tr class="odd">
<td colspan="4"><strong>HOSPITALIZATION</strong></td>
<td colspan="2">Date(s)</td>
<td colspan="12">Name of Hospital</td>
</tr>
<tr class="even">
<td colspan="4"><p><strong>WORK</strong></p>
<p><strong>LIMITATIONS</strong></p></td>
<td colspan="14"><p><strong>Sandia can normally accommodate restricted
physical activity and/or varied work schedule to aid in
rehabilitation.</strong></p>
<p><strong>If any recommendations of this type are necessary, please
indicate type and duration of need in space below.</strong></p>
<p><strong>______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________</strong></p></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="14"><strong>It is the Responsibility of the Employee to
Discuss the Return-To-Work Date with the Physician.</strong></td>
</tr>
<tr class="even">
<td colspan="4"><strong>RETURN TO WORK</strong></td>
<td colspan="8"><strong>Physician</strong> Give Date Employee May Return
to Work.</td>
<td colspan="6">Date Employee May Return to Work</td>
</tr>
<tr class="odd">
<td colspan="4"><strong>ATTENDING</strong></td>
<td colspan="8">Name</td>
<td colspan="6">Telephone &amp; FAX Numbers</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="14">Address</td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="14">I CERTIFY that the patient has been unable to work from
the first day of absence (see top of form) to the indicated
return-to-work date, or is still unable to return to work.</td>
</tr>
<tr class="even">
<td colspan="3">Signature</td>
<td colspan="9"></td>
<td colspan="2"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="12">Physician’s Signature</td>
<td colspan="2"></td>
<td colspan="4">Date</td>
</tr>
<tr class="even">
<td colspan="18">RETURN TO SNL HEALTH SERVICES DEPARTMENT</td>
</tr>
<tr class="odd">
<td colspan="11">New Mexico:</td>
<td colspan="7">California:</td>
</tr>
<tr class="even">
<td></td>
<td colspan="12"><p>P.O. Box 5800 MS 1019</p>
<p>Albuquerque, NM 87185-1019</p>
<p>FAX (505) 845-1046</p></td>
<td colspan="5"><p>P.O. Box 969 MS 9112</p>
<p>Livermore, CA 94551-0969</p>
<p>FAX (925) 294-2392</p></td>
</tr>
<tr class="odd">
<td colspan="18">THIS PORTION FOR SNL HEALTH SERVICES USE ONLY</td>
</tr>
<tr class="even">
<td colspan="2">Date Processed</td>
<td colspan="3"><p>Approved Until</p>
<p>Extension of existing PCD</p></td>
<td colspan="2">MCM Initials</td>
<td><p>Guidelines</p>
<p>ODG Work Loss </p></td>
<td colspan="7"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="18">Notes</td>
</tr>
</tbody>
</table>