APPLICATION FOR ASSAULT LEAVE. Pursuant to the provisions of the negotiated agreements with the Cleveland Heights-University. Heights City School District and the Cleveland Heights ‘Teachers Union, Local 795, AFT, and the OAPSE Locals 102 and 617, 1 hereby apply for assault leave and, in support of my, application, state the following: EmployeeName: Building: I began my absence on: I returned to duty on: I was assaulted on: by: (name of employee or student) at: in the following manner: (place where incident occurred) (furnish brief description of occurrence – use back of form if necessary) The assault was witnessed by: and was reportedto: on (name of supervisor/administrator) EmployeeSignature: Date: If you received medical attention because of the assault, have the attending physician complete the following: I treated on the following dates: and have/will discharge(d) from further treatment on In my opinion, was totally disabled from to and will continue to be totally disabled until The disability for which Itreated is Printed Name of Physician Signature of Physician Date APPENDIX 5 AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION Persons/Organizations authorized to use or disclose Protected Health Information: [Insert name of physician, clinic and/or hospital performing physical examination of employee]
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