SMCIForms

The Physician Qualifying Statement is an SMCI Unit MASE/CWA Form to be used by SMCI MASE members in qualifying for,"Donated Leave" falling under the alternative," a chronic illness or injury". This form is to be completed and signed by the attending physician and submitted along with your request for donated leave paperwork obtained from personnel. It would be a good idea to have an SMCI MASE board member review it for completeness prior to submitting it to personnel.

Senate Bill 2317 requires that a "catastrophic injury or illness" under the statue must be a "life threatening injury or illness," or in the alternative, a chronic illness or injury such as "cancer or major surgery" may be considered catastrophic if:

      1. if the illness or injury is long term in nature
      2. requires long recuperation periods, and
      3.   and would create intermittent absences from work

*** All three of the above requirements must be met to be considered catastrophic*****

        Please make sure you make copies of all submitted documents prior to                   submitting them to personnel. Unfortunately things do get lost!

The Recommendation /Complaint Form is an SMCI Unit MASE/CWA Form that is to be used by SMCI MASE members in submitting ideas that might improve the working conditions at SMCI or it may be used for the submission of problems that have been encountered. When submitting this form please include a copy of any incident reports or other paperwork that you may have pertaining to the situation. This document needs to be submitted to the SMCI Unit MASE/CWA Equity Committee for disposition. It is also very helpful to have written statements from witnesses attached to the document when available.

SMCI Unit MASE/CWA
Forms

Physicians Qualifying Statement
(click on link and print out)

Recommendation/Complaint Reporting Form
(click on link and print out)