REASON FOR REQUEST TO WITHDRAW DAYS FROM SICK BANK Sample Clauses

REASON FOR REQUEST TO WITHDRAW DAYS FROM SICK BANK. Number of days requesting from the Sick Leave Bank: Reason for requesting Sick Bank days: (check one) ( ) Catastrophic illness of employee*

REASON FOR REQUEST TO WITHDRAW DAYS FROM SICK BANK. Number of days requesting from the Sick Leave Bank: Reason for requesting Sick Bank days: (check one) [ ] Catastrophic illness of employee* [ ] Catastrophic illness of employee’s parent, spouse, child, sibling* *Physician’s certification must be submitted in both cases. To request sick bank days for the catastrophic illness of a family member, the employee must also provide convincing evidence that the employee is in fact needed to care for the family member (see Section III below). In your own words, describe the nature of your illness (or the illness of your “family member”): Date you were last actively at work: Date you are expected to return to work: Date illness/injury occurred: Is this injury / illness work related? [ ] Yes [ ] No APPENDIX D: SICK BANK APPLICATION & INSTRUCTIONS (CONTINUED) SICK BANK APPLICATION FORM