SICK LEAVE BANK REQUEST FORM. Employee’s Name I am requesting number of days from the sick leave bank. The reason I am requesting sick leave is:
SICK LEAVE BANK REQUEST FORM. The sick leave bank has been established for use by eligible unit members whose earned sick and personal leave accumulation has been exhausted from a prolonged illness, medically required surgery, or injury and documented in writing by a physician. The application must be submitted in original format no earlier than ten (10) school days prior to a unit member exhausting all of their own personal sick leave days. The Sick Leave Bank Committee shall respond to all applications no later than ten (10) school days from receipt of completed application and all required documentation. Name: School/Location: Date of Request: Number of Days Requested: Date sick and personal leave is exhausted: Reason for Request: Attach medical certification from a healthcare provider that the unit member’s condition prevents the unit member from performing their regular duties. The administration reserves the right to verify the authenticity of any required documentation. I am aware that if additional days are required, I must submit a new application as well as provide additional documentation from the health care provider. Unit members will not receive compensation without the required documentation. Payment cannot be processed until all required approvals are submitted to Payroll by the committee. Unit Member Signature & Date Any grant of sick leave by the Sick Leave Bank Committee to an eligible member shall not exceed twenty (20) days. Upon completion of any grant of sick leave days by the Sick Leave Bank Committee, additional days may be granted upon demonstration of continued eligibility by the applicant. No unit member shall be granted more than one hundred eighty two (182) sick leave days for the same illness by the committee. Approved: #of Days Not Approved: Sick Leave Bank Committee Member Signature & Date Sick Leave Bank Committee Member Signature & Date Director of Human Resources’ Signature and Date APPENDIX C-1 REQUEST FOR EXTENDED LEAVE FORM Name School/Location Pursuant to ARTICLE X, Extended Leaves of Absence, I hereby request the following leave:
SICK LEAVE BANK REQUEST FORM. The sick leave bank has been established for use by eligible unit members whose earned sick and personal leave accumulation has been exhausted from a prolonged illness, medically required surgery, or injury and documented in writing by a physician. The application must be submitted in original format no earlier than ten (10) school days prior to a unit member exhausting all of her own personal sick leave days. Name: School/Location: Date of Request: Date sick and personal leave is exhausted: Number of days requested: Reason for request: Attach certification from a health care provider that the unit member’s condition prevents the unit member from performing her regular duties. The administration reserves the right to verify the authenticity of any required documentation. I am aware that if additional days are required, I must submit a new application as well as provide additional documentation from the health care provider. Unit members will not receive compensation without the required documentation. Payment cannot be processed until all required approvals are submitted to Payroll. Unit Member Signature Date Any grant of sick leave by the Sick Leave Bank Committee to an eligible member shall not exceed twenty
