The 
Department Statement Form is needed by the Disability Benefits Office to process
a disability claim for an eligible employee in your department.
Please complete this form and return to the Disability Benefits
Office as soon as possible. The disability insurance company cannot
complete their disability evaluation until this information is received
by the Disability Benefits Office.
Sick Leave
The employee is required to use accrued sick leave up to 30 calendar days. Even if the employee has a 7-day waiting period, up to 30 calendar days of sick leave must be used if the employee has accrued it. If the employee does not have enough accrued sick leave to cover the waiting period and elects not to use vacation or compensatory time, pay status ends when the employee exhausts all sick leave. If the employee has no sick leave and elects not to use vacation or compensatory time, pay status ends the day the employee leaves work.Vacation or Compensatory Time
Use of vacation and compensatory time is optional, and subject to departmental approval. If use of vacation or compensatory time is elected, it may be used at the beginning of the disability period, following the exhaustion of sick leave.Date of Disability
In order for the employee to receive disability benefits from the disability insurance company, the date of disability must immediately follow the last day actively-at-work. An employee cannot continue working after being certified disabled by a physician and must provide a physician's release to return to work.Payroll Status
When sick leave and vacation/compensatory time, if selected, have been exhausted, the department must put the employee on Leave Without Pay status. Once the employee starts receiving disability benefits, regular UC paychecks should NOT be generated for the employee.Family Medical Leave
If the employee is eligible for Family Medical Leave (FMLA), please attach a copy of the FMLA letter and return with the completed department statement. The employee has been given all the information on Family Medical Leave and is responsible for giving this to the department. Without this letter, Disability Benefits cannot authorize payment of the employee's benefits under FMLA. Keep a copy of the Department Statement for your records.
Send the Return
Confirmation Form as confirmation of
the employee's return to work or pay status.