Medical Separation Checklist

CHECKLIST FOR REQUESTS FOR REVIEW FOR MEDICAL SEPARATION

  1. Has the case been reviewed with the Employee Relations Consultant?
  2. Are there any protected leave status issues (e.g. FMLA, CFRA, PDL)?
  3. Is this a worker’s compensation case, and if so, has the department been in contact with the vocational rehabilitation unit?
  4. Has the department engaged in the interactive process with the employee? How recently did this occur?
  5. Is the Request for Review signed by a manager and is it dated?
  6. Are all the required/relevant parts of the form completed? Are the responses appropriate?
  7. Are all of the relevant/required documents attached and completed?
    • Job description with essential functions annotated (highlighting does not show up on copies).
    • PEM form
    • Medical information indicating either that the employee cannot return to work or can return with restrictions