SEARCH
Philippine Government Forms All in One Location
Tweet
Share
B-300 EC Claim For Temporary Total Disability or Sickness
SSS form used for employee sickness notification
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
SOCIAL SECURITY SYSTEM
EMPLOYEES NOTIFICATION
Form B‐300 (8/75)
IMPORTANT: PLEASE READ INSTRUCTIONS AT THE BACK BEFORE FILLING UP FORM
PART I CONFINED MEMBER'S NOTIFICATION (To be filled up by confined member)
NAME OF CONFINED MEMBER (Please Print in Full)
SS NUMBER
TAX ACCOUNT NUMBER
ADDRESS OF EMPLOYER
RESIDENCE OF CONFINED MEMBER
EMPLOYER'S REGISTERED NAME
EXACT DATE OF CONFINEMENT: PLACE/ ADDRESS OF CONFINEMENT
This is to notify my employer that I am currently confined. The name of employer, the place/address and the date when such confinement started are indicated above. I
certify that I am hereby waiving in favor of the SSS all information which my physician has acquired while attending to me as a patient in a professional capacity which
information was necessary to enable him to act in that capacity. I hereby consent to the examination of my physician as to all information acquire by him from physical/ mental
examination of any person and all results of X-ray, laboratory and/or special diagnostic examinations. I further waive all information held privilege by law.
NAME AND SIGNATURE OF MEMBER'S AUTHORIZED REPRESENTATIVE
(If sick member cannot write, print right thumbmark)
SIGNATURE OF CONFINED MEMBER
(RIGHT THUMBMARK)
(Please sign over your printed name)
PART II MEDICAL CERTIFICATE (This block to be filled by attending physician)
I CERTIFY THAT I HAVE EXAMINED/ATTENDED the above‐named employee and state the following:
EXACT DATE EXAMINED ATTENDED
AGE
SEX
CIVIL STATUS
OCCUPATION
ADDRESS OF CONFINEMENT
THIS IS BEING SUBMITTED AS: (Check applicable box and state corresponding report/ findings)
an INITIAL CERTIFICATE
an INTERMEDIATE
a FINAL CERTIFICATE
CLINICAL SUMMARY (Please read instruction #4 at the back)
PROLONGED CONFINEMENT DUE TO:
DIAGNOSIS
(a) FINAL DIAGNOSIS (Give progress report of patient)
IN MY MEDICAL OPINION the confinement including the convalescing
NO. OF DAYS CONFINEMENT EXTENSION EFFECTIVE (Exact Date)
or recuperation period may last for __________ days.
FIT TO RESUME WORK ON ____________________ (estimated date)
Confinement VERIFIED by employer/company physician
CONFINED AT
WILL BE FIT TO RESUME WORK ON (Exact Date)
Confinement NOT VERIFIED by employer/company physician
PRINTED NAME & SIGNATURE OF ATTENDING PHYSICIAN
PRINTED NAME & SIGNATURE OF EMPLOYER/ ATTENDING PHYSICIAN
ADDRESS OF PHYSICIAN
ADDRESS OF PHYSICIAN
REGISTRATION/ LICENSE NO.
REGISTRATION/ LICENSE NO.
PART III EMPLOYER'S REPORT (This block to be filled up by Employer)
NAME OF CONFINED MEMBER
OCCUPATION (Exact description of work)
TIME OF WORK (Inclusive hours)
Date of Employment
HOW LONG EMPLOYED?
CAUSE OF INJURY
a) Much less or Tool __________________________________________
b) Kind of Power (hand, foot, electrical steam, etc.)
DESCRIBE FULLY HOW ACCIDENT HAPPENED AND STATE WHAT EMPLOYEE
WAS DOING WHEN INJURED.
c) Part of Machine on which accident occurred __________________
d) Was he injured during his regular occupation? ________________
Time, date & place of accident:
Ti
d t
id
EMPLOYER'S/ COMPANY'S ACKNOWLEDGEMENT RECEIPT
(FROM SSS)
EMPLOYER'S ACKNOWLEDGEMENT RECEIPT
(FROM COMPANY)
NAME OF CONFINED MEMBER
NAME OF CONFINED MEMBER
EMPLOYER
ADDRESS
ADDRESS
EMPLOYER
CONFINEMENT PERIOD (Exact Date)
START OF CONFINEMENT (Exact Date)
FROM
RECEIVED BY
TO
DATE RECEIVED
NOTIFICATION RECEIVED BY
DATE RECEIVED
CERTIFICATION BY EMPLOYER
SICKNESS NOTIFICATION WAS RECEIVED BY US ON
START OF CONFINEMENT (Exact Date)
SICKNESS OCCURRED WHILE (working, on leave, etc)
______________ 19 ______ thru: Mail/ Phone
COMPANY HAS NO WAY OF VERIFYING THE SICKNESS BECAUSE: (Check applicable box)
_______________________________
NATURE OF BUSINESS
NO. OF EMPLOYEES
EMPLOYED
The place of confinement was in
Company has no physician
He/she notified us only upon returning to work on
which is ____________ kms away.
COMPANY ID NUMBER
PRINTED NAME OF SIGNATURE OF COMPANY EXECUTIVE
FOR SSS USE ONLY
MEDICAL EVALUATION
FINAL DIAGNOSIS
APPROVED: ____________________ days, from ____________________ to _____________________
REDUCED: ____________________ days, from ____________________ to _____________________
DENIED: ______________________ days, from ____________________ to _____________________
CLAIMANT TO COME FOR PHYSICAL EXAMINATION/CHEST X-ray
Submit: ____________________________________ Returned: _______________________________________
PREVIOUSLY APPROVED CONFINEMENT PERIOD: From ___________________________ to _____________________________
(Exact Date)
(No. of Days)
SIGNATURE OF SSS MEDICAL EXAMINER/ RETAINER PHYSICIAN
RECONSIDERATION/ EXTENSION:
No. of Days
DATE EVALUATED
FROM
TO
MEDICAL EXAMINER
DATE
IMPORTANT INSTRUCTIONS
1. The employee shall notify his employer of his sickness or injury within five (5) calendar days after the start of his confinement. Within five (5) days from receipt of
notice or knowledge of the sickness or injury, the employer shall record in his logbook the facts thereof and within five (5) days thereafter the employer shall notify the
Medical Evaluation Section of the nearest SSS branch or Representative Office. However, in cases where the sickness or injury sustained by the employee while working or
within the premises of the employer, the employee shall be deemed to have notified his employer. The foregoing prescription period of NOTIFICATION does not apply to
HOSPITAL confinement.
2. This form, after having been properly accomplished, shall be submitted in two (2) copies to the Employer by the sick employee or his representative. The employer
shall submit the ORIGINAL to the Medical Evaluation Section of the SSS branch or Representative Office within the prescribed period in instruction No. 1.
3. Use this form for the purposes of an INITIAL SICKNESS NOTIFICATION and INTERMEDIATE or FINAL SICKNESS NOTIFICATION, with the Attending Physician
checking the proper box in the PART II, (Medical Certificate Portion) of this form.
4. For the items "CLINICAL SUMMARY" and " PROLONGED CONFINEMENT DUE TO" in PART II of the form, symptoms, physical findings, laboratory examinations
and reports; X-ray plates; special diagnostic procedures. If any, must be submitted with this form. In cases of prolonged confinement, a progress report of the patient, in
addition to those already stated, must be submitted. If spaces provided are not enough, attach an additional sheet herewith.
5. In cases of prolonged confinement or sickness of the employee that will extend beyond the initial estimate, on a previous estimated period, this form will be
accomplished again by the employee and his Attending Physician, and submitted to the SSS within five (5) days requirement, after the previous estimate, and the Attending
Physician will check the applicable boxes in PART II thereof.
6. For further details, refer to EC Circular No. 2-1 re: Sickness Notification requirement and procedures.
7. Physical examination will be held only in the morning from 8:00 to 12:00, Monday thru Friday. Those who cannot come should notify the SSS, Medical Evaluation
Section of the SSS branch or Representative Office immediately.
