1. Secure an appointment for the cancer screening at least two weeks in advance of notifying the District personnel office of your intent to receive the screening (see form on next page). 2. Use the form “Notice of Appointment for Cancer Screening” that accompanies this attachment, or request a copy of the form from the personnel office. Complete Part A of the form, and send it to the personnel office (Tim Lange). 3. The personnel office will return a copy of the notice to you with Part B completed. Bring the copy with you to the location where the screening takes place. Have Part C completed by the medical staff at the time of the screening. 4. Return the completed form to the District personnel office upon your return to work. Should you have any questions regarding this procedure, please feel free to contact Tim Lange. Please print the form below or download attachment.
East Greenbush Central School District
Notice of Appointment for Cancer Screening
This form is to be used by any East Greenbush Central School District employee to notify the District of a scheduled appointment for, and to provide the District with documentation of, a screening for breast or prostate cancer for which personal leave from work is necessary.
Directions to Employee: Complete Part A below and send form to the District personnel office. District administration will complete Part B. You will receive a copy of the form from the personnel office. Bring the copy with you to the screening and have medical staff complete Part C. Return the completed form to the District personnel office.
PART A – To be completed by employee after securing an appointment for cancer screening
Employee Name __________________________________________
Building(s)/Department __________________________________________
Date of Appointment __________________________________________
Location of Screening __________________________________________
PART B – To be completed by District administration
Date form received __________________________________________
Reviewed by __________________________________________
PART C – To be completed by medical staff
Date of Screening ______________________________________
Screening Type: ______Prostate ______Breast
Signature of Medical Staff Completing This Form
______________________________________