Sick Leave Form
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See Instructions on Second Page
Name: ____________________________ request to use ___________ hours of Sick Leave:
Starting Date (mm/dd/yy): _____________
Starting Time (hh:mm): ___________
Ending Date (mm/dd/yy): _____________
Ending Time (hh:mm): ___________
No
Reason for Sick Leave:
Family Medical Leave: ___________
If FMLA applies, date the FMLA
certification was/will be provided: _______
_________________________________
__________________
Signature of Employee
Date
Attach this form to Timesheet applicable to the absence
Privacy Notice:
Please see section in instructions concerning privacy.
HealthCare Provider Statement
(in lieu of other documentation):
(Required if absence is more than 48 scheduled hours for 24/48 employees or 24 hours for 40 hour employees)
The above named employee has been under my care during the above period of
time. The employee's absence from duty was medically necessary for this period.
The employee is _____or is not _____ (check) able to return to duty in some
limited/light duty capacity (such as no lifting over x pounds, no twisting, seated
work only etc).
Firefighters on light duty do administrative tasks such as desk duty,
telephone answering, document filing. Also, being for a limited number of hours per day can
be accommodated.
Earliest date employee may begin limited/light duty (if capable): _________________
Limited/light duty restrictions:
Date employee is ___ may be ___ released to return to full duty: __________________
_________________________________
_________________
Signature of Healthcare Provider
Date
Received by Scheduling Officer: ____________________________ Date: ______________
Received by Fire Chief: _______________________________
Date: ______________
E-Mail to Scheduling
E-Mail to Chief
Print
Save As
E-Mail to P-1 Sup
E-Mail to P-2 Sup
E-Mail to P-3 Sup
E-Mail to
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Parent category: Legal