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The Short Term Disability Form is a essential document used in New Zealand workplaces when an employee needs to request temporary disability benefits due to illness, injury, or other medical conditions not covered by ACC. This form is designed to comply with New Zealand's employment legislation, privacy laws, and health and safety requirements. It collects comprehensive information about the employee's condition, work status, and medical certification while protecting sensitive personal information. The document facilitates communication between all involved parties - employee, employer, medical providers, and insurers - and helps determine eligibility for short-term disability benefits. It's particularly important for maintaining accurate records and ensuring proper processing of disability claims in accordance with New Zealand employment standards and insurance requirements.

1. Personal Information: Employee's basic details including name, date of birth, contact information, and IRD number

2. Employment Details: Current employment information including employer name, occupation, work hours, and employment status

3. Disability Information: Nature of disability, date of onset, expected duration, and impact on work capabilities

4. Medical Provider Information: Details of treating healthcare provider(s) and relevant medical certifications

5. Current Work Status: Information about last day worked, return to work date if known, and any modified duty capabilities

6. Income Information: Details of current salary/wages and other income sources

7. Privacy Statement: Statement regarding collection, use, and disclosure of personal information

8. Declaration: Employee's confirmation of truth and accuracy of provided information

9. Authorization: Consent for collection and sharing of medical information with relevant parties