Sick Leave Pool Contribution/withdrawal Request printable pdf download

University of Houston System

Sick Leave Pool Contribution/Withdrawal Request

Employee Information:

Name: _________________________________________________ Empl ID: _______________________________

Home Address: ___________________________________________ State _______________ Zip _______________

Department: ____________________________________________ Campus: _______________________________

Supervisor Name ______________________________________________ Telephone # _______________________

Sick Leave Pool Contribution

Number of hours you wish to contribute: ____________(Contributions must be made in increments of 8 hours)

Are your retiring or terminating employment? _______ Yes ______ No

Participation in the Sick Leave Pool is voluntary and the contributions are irrevocable. The number of hours

contributed cannot exceed your accrued sick leave balance. If your exhaust all your accrued sick leave hours due to

non‐catastrophic illness you may request a withdrawal from the Sick Leave Pool in the amount of hours that you

may have donated in the current fiscal year. Hours contributed to the Sick Leave Pool due to termination or

retirement cannot be refunded should you return to state employment.

Signature: ____________________________________________ Date: ___________________________

Sick Leave Pool Withdrawal

Number of days requested: ____________ (Minimum of 5 days, Maximum of 30 days)

Have you exhausted all other types of paid leave?

Yes ___ No ___

Has the current catastrophic illness or injury exceeded 90 days or expected to exceed 90 days? Yes ___ No ___

Have you attached a physician statement that includes diagnosis and estimated length of disability? Yes ___ No ___

Have you filed application for benefits under Short Term/Long Term Disability plan, if applicable? Yes ___ No ___

I understand that my Sick Leave Pool withdrawal request will be processed on a first come, first served basis. The

number of days I may be granted is based on the number of hours available in the pool. I understand I may not

receive the full amount requested. I understand that any unused hours must be returned to the Sick Leave Pool.

Sick leave time cannot be used until your sick leave balance is updated in the next available payroll cycle. The

University reserves the right to require a second (2

) opinion. Some employees are ineligible for Sick Leave Pool,

including those with less than 50% FTE; irregular, seasonal, temporary or student workers; workers compensation

and others as listed in the University Policy. The lifetime maximum for Sick Leave Pool withdrawals is 90 days, with

no more that 30 days allowable per withdrawal.

I understand that I must also apply for FMLA within 3 days of first being absent from work.

Signature: ____________________________________________________ Date: __________________________

rere

Supervisor Signature: ___________________________________________ Date: __________________________

Sick Leave Pool Contribution/withdrawal Request