Republic of the Philippines

SOCIAL SECURITY SYSTEM

SU - 01252 (12- SICKNESS NOTIFICATION
2015)
CLAIM NO. RE-FILING CLAIM NO.
TNIS FORM MAY BE REPRODUCED AN IS NOT FOR SALE. THIS CAN ALSO BE DOWNLOADED THRU THE SSS WEBSITE AT www.ses.gov.pI'i
PLEASE READ THE INSTRUCTIONS AND REMINDER AT THE BACK BEFORE FILLING OUT THIS FORM. PRINT ALL INFORMATION IN CAPITAL
LETTERS AND USE BLACK INK ONLY.
PART I - TO BE FILLED OUT BY THE MEMBER
A. PERSONAL DATA
SS NUMBER COMMON REFERENCE NUMBER ‹ir any DATE OF BIRTH fuuoo TAX IDENTIFICATION NUMBER ‹iF aNYj

\rinsz uxu£j tuioocE NAuE) (sUFrix)

ADDRESS (RM,FUR2UMmNO &BtDGNAm‹# (NOUSULOT6BLxw0)

(SUBDIVISION} (PROVINCE) ZIP CODE

I I I
TELEPHONE NO. ‹xnex cooE • TzL MOBILE/CELLPHONE NO. E-MAIL ADDRESS
no.j

FOREIGN ADDRESS ir xeeL/cxeLzj COUNTRY ZIP CODE

B. CERTIFICATION
I certify that the information provided in this form are true and correct.

PR NTE AME SIGNATURE DATE

If member cannot sign, affix fingerprints. Please read Instruction No. 6 of the form.
Below are the witnesses to fingergrintins:

R NTE AME SIGNATURE DATE

AD Et$S & CONTACT NUMBER

2)

PR NTE AME SIGNATURE DATE RIGHT THUMB l RIGHT INDEX

CAN y A RESS ACT NUMBER
PART II - TO BE FILLED OUT BY EMPLOYER
A. EMPLOYER DATA
EMPLOYER ID NUMBER NAME OF EMPLOYER/REGISTERED BUSINESS MAME E-MAIL ADDRESS

BUSINESS ADDRESS *NO. & STREE7) (TO\M'+/ OisTRICT) (CIXV/PROVINCE} ZIP CODE

START OF SICK LEAVE NOTIFICATION FORM WAS E-NOTIFICATION DATE ACCIDENT/SICKNESS OCCURRED WHILE
(MMDDWYY› RECEIVED BY US ON (MMDDWYY› (MMODWYY} Working In Co. Premises On Vacation
On Strike Co. Shutdown Under Suspension
B. CERTIFICATION
I certify that the above information are true and correct and that the reported accident/illness is duly recorded in the
Employer's Logbook for EC Claim under page number and entry number

EUR SIG TU E O PRINTE ME OFFICIAL DESIGNATION DATE

EMPLOYER/AUTHORIZED REPRESENTATIVE
PART III - MEDICAL CERTIFICATE (TO BE FILLED OUT BY THE ATTENDING PHYSICIAN)
BRIEF MEDICAL HISTORY AND PERTINENT FINDINGS

ATTENDING PHYSICIAN'S CERTIFICATION

I certify that I have seen and examined above-named patient on and in my opinion, confinement
(DATE)
including recuperation period may last days.
(no. of days)
DIAGNOSIS: FIT TO WORK:
PLACE OF CONFINEMENT START OF NAME OF HOSPITAL (if confined in a hospital)
CONFINEMENT

PRINTED NAME AND SIGNATURE LICENSE NO.

S {TOWN/ DISTRICT} (CITY/PROVINCE} ZIP CODE
ADDRESS OF PHYSICIAN’S CLINIC/HOSPITAL ^ ^
i i i
PART IV - TO BE FILLED OUT BY SSS PERSONNEL
RECEIVED BY (FOR MEMBER SERVICES SECTION) RECE(VED BY (FOR MEDICAL EVALUATION SECTION)

DATE TIME SIGNATURE OVER PRINTED NAME TIME

• Perforate Here
N¥pMouc 9r MY# NWGTggYn¥6
SOCIAL SECURITY SYSTEM
SICKNESS NOTIFICATION
ACKNOWLEDGEMENT STUB
SS NUMBER/CRN ‹ir an'o NAME OF MEMBER *^ S* ME} (FIRSTNAME) (SUFFIX)

RECEIVED BY

SIGNATURE OVER PRINTED POSITION DATE & TIME SSS BRANCH

NAME TITLE
 THIS PORTION TO BE FILLED OUT BY SSS PERSONNEL
PART V - SCREENING RESULTS
MEMBER SERVICES SECTION MEDICAL EVALUATION SEC•TION
Screening was done and results are as follows: Screening was done and results are as follows:
In order @ In order
No signature of Employee With findings, please see Remarks
No signature of Employer Remarks:
Medical Certificate not accomplished
Remarks:

SCREENED BY SCREENED BY

SIGNATUREOVERPRINTEDNAME DATE TIME SIGNATURE OVER PRINTED NAME DATE TIME

RECEIPT AND SCREENING (RE-FILED CLAIM) REMARKS
@ Claim accepted
@ Claim not accepted (see remarks)
RECEIVED AND SCREENED BY

SIGNATURE OVER PRINTED NAME DATE TIME DATE RETURNED

PART VI - MEDICAL EVALUATION
A. PHYSICAL EXAMINATION AND INTERVIEW
PERTINEN r PE FINDINGS (Member to amx signature after PEI) Onset of Illness
Last Working Day
Back to Work

Member's Signature
B. RECOMMENDATION
SS EC
APPROVED # of days APPROVED ¥ of days
\ ) Initial Mention (indicate previous approval) Initial Extension (indicate previous approval)

(In numeric) (In words) (In numeric) (In words)

(lndusive Penod) (lndusive Period)

Prevous appoval Previous approval
HospitN (Confined) ( j Hospital (Confined)
(Date of Discharge) (Oale of Discharge)
PENDING - For MFS HCD/ODS referral PENDING - For MFS HCD/ODS referral

Initials murals Date

RETURNED - RETURNED-

Initials Date Initials Date

DENIED - DENIED -

REMARKS REMARKS

ILLNESS CODE/S

EVALUATED BY ENCODED AND RELEASED BY

SIGNATURE OVER PRINTED NAME DATE IG TURE OVER PR NTE NAME DATE

INSTRUCTIONS
1) Fill out this form in one (1) copy. ON FILING OF NOTIFICATION
2) Always indicate "hI/A" or "Not Applicable", if the required data is For Employed Members
not applicable. - To avoid penakies tor late filing, Sickness Notification (SN) form must be
3) Please attach this notification to the Sickness Benefit submited to employer within five (5) calendar days after start of
Reimbursement confinement, except:
Application a) if confinement is in a hospital - deadline for notification is one (1) year
4) Affix your initials on all alterations/erasures in this form.
5) Write SS Number and name of member in all the supporting from date of discharge
documents submitted. b) if sickness/injury occurred while at work or within company premises -
6) If member cannot sign, witnesses to fingerprinting shall be as Employer is deemed notified.
foIk›ws: For EC cases, sickness/injury must be recorded in the company k›gbook
- Two (2) witnesses: One (1) witness is the within five (5) calendar days from notice or knowledge of occurrence of
employer/authorized representative and the other one (1) the contingency. Failure to do so will mean employer liability to fifty (50)
could be any person. Both should affix their signatures and percent d the lump sum equivalent of the income benefit the employee is
indicate their addresses and contact numbers on the entitled.
portions provided in Part I-B.
ATTACHMENT/SUPPORTING DOCU tENTS
I s e For Employers
ed
- Laboratory, X-ray, ECG and other diagnostics results To avoid penahies for late filing, employer may:
- Operating room/dinical record that will support a) File the SN fom at SSS within five (5) calendar days after its receipt
diagnosis For sickness that occurred while on from employee, including cases where sicknessfinjury occurred while
strike/shutdown at work or within company premises, or
- Certificate of Notice of Strike issued by DOLE b) Notify the system through the web and submit tha SN form within thirty
- Certificate of Foreclosure (30) calendar days after date of web notificafion.
- Certificate of Non-advancement of Payment from
Employer For vehicular accident w/ 3rd party invoNement
(EC daim)
- Police Report
 REMINDER
Verification of status may be made thru the SSS Website at www.sss.gov.ph or contact our Call Center at 920-6446 to 55 or 917-7777.