Sick Leave Pool Withdrawal Request Form
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1PRAIRIE VIEW A&M UNIVERSITY
Office of Human Resources
Sick Leave Pool Withdrawal Request Form
Privacy Notice: State law requires that you be informed that you are entitled to: (1) request to be informed about
the information collected about yourself on this form (with a few exceptions as provided by law); (2) receive and
review that information; and, (3) have the information corrected at no charge. To request this information, contact
leaveteam@pvamu.edu
or (936) 261-1728.
This form is used by employees to request a withdrawal of sick leave hours from the sick leave pool.
Employee Name: __________________________________
UIN: _______________________________
Department: ______________________________________
Mail Stop: ___________________________
Number of hours requested: __________
(Sick leave pool withdrawals should be requested as soon as the need becomes apparent. Pool hours cannot be
awarded retroactively.)
Purpose of Withdrawal:
____ Catastrophic illness or injury. I expect to exhaust my sick and vacation leave and compensatory time as of
_______________ (time) on _______________ (date). I expect to have missed 160 hours of work due to this
illness or injury as of _______________ (time) on _______________ (date).
Attached is a physician’s
statement stating the nature and expected duration of the illness or injury.
____ Is this request a result of an on-the-job injury? ____ Yes ____ No
(Policy prohibits sick leave pool from being used in conjunction with a workers’ compensation claim.)
If requesting time to care for an immediate family member:
_______________________________________________
____________________________
Family Member’s Name
Relationship
_______________________________________________
____________________________
Employee Signature
Date
I certify that this employee has exhausted all earned sick and vacation leave and compensatory time as of
_______________ (time) on _______________ (date) and that the employee has missed 160 hours of work for this
condition as of _______________ (time) on _______________ (date).
_______________________________________________
____________________________
Department Head Signature
Date
Number of hours approved: __________
Comments: ___________________________________________________________________________________
_____________________________________________________________________________________________
_______________________________________________
____________________________
Leave Administrator Signature
Date
SUBMIT FORM TO:
FOR ASSISTANCE:
Leave Services
Leave Services
Harrington Science Bldg. Room 109
(936) 261-1728
Fax: (936) 261-1734
or
Email:
leaveteam@pvamu.edu
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