Form UC-6QA: Physician's Certification for Quit to Care for an Ill Relative

Form UC-6QA: Physician's Certification for Quit to Care for an Ill Relative

State of Connecticut Department of Labor, Employment Securing Adjudications

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Name

First NameLast Name
Social Security Number
Enter the 9 digits of your Social Security Number (SSN).
Section 31-236 of the Connecticut Unemployment Compensation Law provides, in part, that no individual shall be ineligible for benefits if the individual leaves suitable work to care for a seriously ill spouse or child, or parent domiciled with the individual, provided such illness is documented by a licensed physician.

The above named individual has filed a claim for unemployment compensation and states that he/she is responsible for the care of _____________________________________, who is the individual's (circle one of the following:) Spouse Child Parent.
Benefit Eligibility Criteria

The information requested below is essential for making a proper determination of eligibility for benefits.
Please use the space below to describe the nature of the illness.
Enter your response in the space above.
Is this a serious illness?

YesNo
Does the illness require continuing daily care?

YesNo
If the illness requires continuing daily care, please use the space below to describe what type of continuing daily care is required. (Daily care might include activities like assisting with medications and personal hygiene, preparing meals, and providing transportation to doctor appointments and/or therapy.)
Enter your response in the space above.
Are you a licensed physician?

YesNo
Physician Information
Physician's Name

First NameLast Name
Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician's Telephone Number

Area CodePhone Number
Physician's Fax Number
Physician's Signature
Date

MonthDayYear
Should be Empty:

Form UC-6QA: Physician's Certification for Quit to Care for an Ill Relative

Print a PDF Version of This Form

Benefit Eligibility Criteria

Physician Information