Scribd Logo
Upload

Welcome to Scribd!

  • Physical Fitness Take 2

    Uploaded by

    Ali Guitron
    48 views1 page
    This document is an annual physician certification form for the California Department of Corrections Physical Fitness Incentive Pay program. It requires employees to submit certification from a licensed health care provider confirming the employee's ability to participate in the program. The form provides instructions for employees and health care providers to complete sections certifying the employee's medical examination date and physical fitness. It also specifies the pay rates of $65 or $130 per month that employees will receive depending on their qualifying time in the bargaining unit.

    Original Description:

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This document is an annual physician certification form for the California Department of Corrections Physical Fitness Incentive Pay program. It requires employees to submit certification from a licensed health care provider confirming the employee's ability to participate in the program. The form provides instructions for employees and health care providers to complete sections certifying the employee's medical examination date and physical fitness. It also specifies the pay rates of $65 or $130 per month that employees will receive depending on their qualifying time in the bargaining unit.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    48 views1 page

    Physical Fitness Take 2

    Uploaded by

    Ali Guitron
    This document is an annual physician certification form for the California Department of Corrections Physical Fitness Incentive Pay program. It requires employees to submit certification from a licensed health care provider confirming the employee's ability to participate in the program. The form provides instructions for employees and health care providers to complete sections certifying the employee's medical examination date and physical fitness. It also specifies the pay rates of $65 or $130 per month that employees will receive depending on their qualifying time in the bargaining unit.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 1

    STATE OF CALIFORNIA

    ANNUAL PHYSICIAN CERTIFICATION


    COC 3026 (Rev 07/04)

    DEPARTMENT OF CORRECTIONS

    PHYSICAL FITNESS INCENTIVE PAY

    ANNUAL PHYSICIAN CERTIFICATION


    This form is to be submitted directly to the Personnel Office by the employee. This certification expires with the ending of the state of California fiscal year, and must be renewed on an annual basis.

    TO BE COMPLETED BY EMPLOYEE
    EMPLOYEE NAME (Please Print) EMPLOYEE SOCIAL SECURITY NUMBER

    INSTITUTION/PAROLE

    REGION/OFFICE

    AGENCY/REPORTING

    UNIT NUMBER

    EMPLOYEE

    SIGNATURE

    DATE

    TO BE COMPLETED BY AUTHORIZED HEALTH CARE PROVIDER


    HEALTH CARE PROVIDER CERTIFICATION
    This is to certify that on , I examined the employee named above and physical condition. The examination was conducted using the usual standards recommended provider identified below for examinations, and incorporated the medical tests necessary to assess condition of this person given his/her age, gender, medical history and results of the aforementioned
    HEALTH CARE PROVIDER SIGNATURE

    to determine his/her medical by the medical organization/ the physical and/or medical examination.

    IDATE
    ADDRESS AND TELEPHONE NUMBER

    HEALTH CARE PROVIDER

    NAME (Please Print)

    NAME OF MEDICAL ORGANIZATION/PRACTICE

    TO BE COMPLETED BY PERSONNEL
    DATE RECEIVED IN PERSONNEL EFFECTIVE DATE DATE PAR KEYED

    RATE OF PAY FOR WHICH EMPLOYEE IS ELIGIBLE Bargaining Unit (BU) 6, S06, M06, E97, E98, and E99 employees $65 per month aligned with BU 6, with less than 60 qualifying pay periods' in the unit shall receive a flat rate of $65 per pay penod.

    A qualifying pay period is defined as 11 days of work or more for full time employees and 88 hours of work or more for permanent intermittent employees in a pay period.

    D $130
    PERSONNEL

    per month
    SPECIALIST

    BU 6, S06, M06, E97, E98, and E99 employees aligned with BU 6, with 60 or more qualifying pay periods" in the unit shall receive a flat rate of $130 per pay period. DATE

    SIGNATURE

    ORIGINAL - Personnel Office Copy (To be mainlained in Official YELLOW - Employee Receipt (After review and completion by PINK - Employee Copy

    Personnel Personnel)

    File)

    You might also like