Sick Leave Disability Extension Form Checklist: F 2026

1. Click ‘Get Form’ to open the Sick Leave Disability Extension Form Checklist: F in the editor.
2. In Part 1, Employee Section, fill out your personal contact information. Ensure all fields are legible and complete. Check the box indicating if this is an address change.
3. Provide dates of illness, injury, or disability in Section 1-B. Make sure the Last Day Worked and First Date Absent match the Employer's records.
4. In Section 1-C, confirm that the illness or injury is your own by checking 'Yes'. If applicable, provide details about any related claims.
5. Sign and date in Section 1-D to certify your request for sick leave or disability extension.
6. Once completed, proceed to Part 2 for Employer Section where your employer will fill out their required information and sign.
7. Finally, ensure that Part 3 is completed by your physician if necessary. This includes their signature and date after your appointment.

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