Sick Leave Bank Contribution Form. 28 SICK LEAVE BANK MEMBER’S REQUEST FOR CONSIDERATION ........ 29 SICK LEAVE BANK MEMBER’S REQUEST FOR EXTENSION OF LEAVE 30 COLLECTIVE BARGAINING AGREEMENT BETWEEN THE DALLAS SCHOOL DISTRICT AND
Sick Leave Bank Contribution Form. 1. NAME STAFF ID NUMBER 2. SCHOOL _ Check one: New Member of Sick Leave Bank (2 sick days) Retirement Contribution to Sick Bank I understand that by affixing my signature below I state that I have read and agree to abide by the Rules and Regulations contained in the Sick Leave Bank, and I authorize the deduction of the specified sick leave days from my personal accumulation of sick leave days in this School Corporation. I further understand that these days will be placed in the Sick Leave Bank. It is understood that, if any of the above information is believed to be incorrect by the Office of the Superintendent, the contributing teacher shall be notified by the Superintendent’s Office so that the proper corrections may be made. Signature Date =============FOR OFFICE USE============ Number of days contributed to the Sick Leave Bank Total remaining sick leave days Xxxxxxxx Southeastern Schools Sick Leave Bank Request Form Section A Applicant: Please complete Section A. Please print legibly or type. Date: Name: Employee Number: School/Department: Telephone Number: Home Mailing Address: Street City Zip Have you submitted a Request for Leave to your principal/supervisor? YES NO Describe your illness, accident, or injury: Dates you are requesting to be paid from the Bank: From through
Sick Leave Bank Contribution Form. 1. NAME STAFF ID NUMBER
Sick Leave Bank Contribution Form. 1. NAME _____________________________________________ STAFF ID NUMBER __________________ 2. SCHOOL ______________________________________________________________________ Check one: _______ New Member of Sick Leave Bank (2 sick days) _______ Retirement Contribution to Sick Bank (up to 25 sick days) I understand that by affixing my signature below I state that I have read and agree to abide by the Rules and Regulations contained in the Sick Leave Bank, and I authorize the deduction of the specified sick leave days from my personal accumulation of sick leave days in this Corporation. I further understand that these days will be placed in the Sick Leave Bank. It is understood that, if any of the above information is believed to be incorrect by the Office of the Superintendent, the contributing teacher shall be notified by the Superintendent’s Office so that the proper corrections may be made. __________________________________ ____________________________ Signature Date =============FOR OFFICE USE============ Number of days contributed to the Sick Leave Bank __________ Total remaining sick leave days __________ Xxxxxxxx Southeastern Schools Sick Leave Bank Request Form Section A Applicant: Please complete Section A. Please print legibly or type. Date: ____________________ Name: _____________________________________ Employee Number: ________________ School/Department: __________________________ Telephone Number: ________________ Home Mailing Address: __________________________________________________________ Street City Zip Have you submitted a Request for Leave to your principal/supervisor? YES NO Describe your illness, accident, or injury: ____________________________________________ ______________________________________________________________________________ Dates you are requesting to be paid from the Bank: From ____________ through ____________ The Sick Leave Bank is designed to ease the financial impact of members with a serious illness, accident, or injury that causes absence from work for an extended period of time. Serious illness is defined as being hospitalized, homebound under psychiatric care, temporarily totally physically disabled, and/or not able to perform the majority of essential daily living activities. Do any of these apply to your medical condition? YES NO Is the injury and work missed due to an automobile accident covered under an automobile insurance policy? YES NO After the employee has used all accrued sick leave, and upon approval o...
