Application For Leave Of Absence Due To Illness Form Page 2
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1
2DEPARTMENT REPORT
First Working
Total of
Date of Absence __________________
Sick Days Off __________________
Sick Hrs. Off _______________
Excl. RDO & Holiday
Visiting Doctor
Code 1
By Doctor at Home or Office
Code 2
No Doctor
Code 3
At Hospital
Pass No. _______
Payroll No. _________
Title code __________
Section _________
Date of Appt. __________ Date Hired _____________
_______________________________________________________________________________________
Additional sick leave shall be provided at 75% of what the employee would have been paid if he/she worked in accordance with his/her regular
schedule:
(Please check)
Yes
No
a) have been absent due to illness for 9 or more consecutive work days and;
________
________
b) have exhausted their sick leave bank and;
________
________
c) have 3 or more years of sevice in the SSSA / TWU 106 (TSO/QSA/CRT only)
at the beginning of the sick leave year and;
________
________
d) were eligible for an allowance of 12 sick leave days in the leave year
________
________
The additional sick leave shall not be accumulated from year to year but shall be available to the covered employee in each year. The additional sick
leave pay shall be retroactive to the first day of illness or the date employee’s sick leave bank is exhausted, whichever is earlier.
_______________________________________________________________________________________
e) If answers to questions a) through d) are Yes, employee is eligible for an additional 60 days when recommended by the department.
_______________________________________________________________________________________________
Interim Report:
Code 1
This is the ONLY report for this illness.
Code 2
This is the first of several reports to be submitted for same illness.
Code 3
Previous report or reports were submitted.
Code 4
Final report where interim reports have been submitted.
First Day of Absence (if previous application was submitted) ______________________________________________________________________
Balance of Sick Leave as of _________________________
Days
Hours
Unused (75%/100%) Sick Leave Allowance ________________________
________________
________________
Approved with pay on this application _______________________
________________
________________
Balance (75%/100%) allowance ________________________________
________________
________________
_______________________________________________________________________________________
Days
Hours*
Night Dif. Hrs. ___________________________
APPROVED with 75%/100% pay_________
____________
___________
DISAPPROVE __________________________________
(Reason)
______________
__________
____________________________________________________
TAX EXCLUDED
AMOUNTS TO BE PAID
Pro
Night Diff.
Type
Code
Hours*
Days
Rate
Rate
Hrs.
Min.
8 - 9
10 - 14
15 - 16
17 - 19
34 - 38
39 – 44
Current 75%/100% sick
02
Non-current 75% sick
04
_________________________________
______________________________
___________________________
(Certtifying Official)
(Title)
(Date)
_________________________________
______________________________
___________________________
(Department Head)
(Title)
(Date)
*Show 75% of pay hours for days allowed
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