Sick Leave Bank Leave Request Form
Download a blank fillable Sick Leave Bank Leave Request Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Sick Leave Bank Leave Request Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1LAKE COUNTY SCHOOLS
SICK LEAVE BANK LEAVE REQUEST FORM
Name ______________________________________________________________________________________________
Date of Application ___________________________________________________________________________________
Mailing Address ______________________________________________________________________________________
Street or Box Number
City
State
Zip
______________________ (____)________________ __________________ __________________________________
EIN
Home Phone Number
Work Location
Job Title
Eligible employees are entitled under School Board Policy 6.911 to a maximum of eighty (80) days of paid, job-protected
leave for certain individual medical reasons. Submit this request form to the Sick Leave Bank Administrator at least thirty
(30) days before the leave is to commence, when practicable. Use of the sick leave bank counts towards FMLA leave used
by employees.
For determination of eligibility, please answer each of the following questions. Put a check (√) in the appropriate response
column.
YES
NO
___
___
Is this your first claim for this particular condition?
___
___
Have you used the bank before?
___
___
Have you exhausted all of your accrued sick leave days?
___
___
Have you attached to this application a signed STATEMENT OF
PHYSICIAN verifying this condition?
___
___
Is your claim for cosmetic surgery or for elective surgery which could
safely be scheduled during a non-work period?
In addition to the statement provided by my personal physician, I also agree to submit to an examination by a physician(s) of
the School Board’s choice, if requested to do so.
____________________________________________________________________________________________________
Employee Signature
____________________________________________________________________________________________________
Bank Administrator Signature if Employee unable to sign
DATES OF SICK LEAVE REQUESTED
I request leave from _______________________________________
to _______________________________________
I request a reduced schedule on the following dates ___________________________________________________________
____________________________________________________________________________________________________
I request intermittent leave according to the following schedule _________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
The total number of days of Sick Leave Bank leave that I request is ______________________________________________
EMPLOYEE STATEMENT
I agree to return to work on _________________________. If circumstances change such that I will not be able to return to
work on that date, I agree to notify my supervisor within two days with updated leave information and will submit an updated
Physician Statement to the Sick Leave Bank Administrator.
Signature ________________________________________________________ Date _______________________________
TO BE COMPLETED BY THE SICK LEAVE BANK ADMINISTRATOR
Prior Sick Leave Bank leave requests confirmed _____________________________________________________________
Leave is
Approved
Denied for the following reason(s): ___________________________________________________
____________________________________________________________________________________________________
Sick Leave Bank Administrator Signature
Date
MIS 72_030 2/3/11 RVS
Copies: Employee
Submitted by Compensation and Employee Relations
Compensation and Employee Relations
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business