Form UC-28: Physician’s Certification of Claimant’s Health

Form UC-28: Physician’s Certification of Claimant’s Health

State of Connecticut Department of Labor, Employment Securing Adjudications

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Form UC-28: Physician’s Certification of Claimant’s Health >

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Claimant's Name

First NameLast Name
Social Security Number
Enter the 9 digits of the claimant's Social Security Number (SSN).
I authorize the release to the Connecticut Department of Labor of such medical information that may be required to determine my eligibility for Unemployment Compensation Benefits.
Claimant's Signature
Date

MonthDayYear
Questions for Claimant's Physician

The above referenced individual has filed a claim for unemployment benefits and has named you as his doctor or healthcare provider. In order to properly determine eligibility, we require the information requested below.
Is this individual under your care?

YesNo
Please use the space below to describe the nature of the individual's illness.
Enter your response in the space above.
Did the individual recently separate from employment due to this medical condition?

YesNo
If the individual recently separated from employment due to this medical condition, did working conditions cause or aggravate the medical condition (in your professional opinion)?

YesNo
If in your professional opinion working conditions caused or aggravated the medical condition, please use the space below to explain how.
Enter your response in the space above.
In your professional opinion, was it necessary for the individual to leave his/her position for health reasons?

YesNo
Please use the space below to explain your decision regarding whether the individual needed to leave his/her position for health reasons.
Enter your response in the space above.
Is the individual able to work full time?

YesNo
If the individual is able to work full time, when did the individual become able to work full time? Please enter the date below.

MonthDayYear
If the individual is able to work full time, please use the space below to explain any restrictions.
Enter your response in the space above.
Physician Certification
Physician's Signature
Physician's Title
Physician's Phone Number

Area CodePhone Number
Date

MonthDayYear
Date
Should be Empty:

Form UC-28: Physician’s Certification of Claimant’s Health

Print a PDF Version of This Form

Questions for Claimant's Physician

Physician Certification