Form Ms 408 - State Employees' Leave Bank Request Form
ADVERTISEMENT
1STATE EMPLOYEES' LEAVE BANK REQUEST FORM
TO BE COMPLETED BY EMPLOYEE
(Please TYPE or PRINT)
Name*:
SS#*:
* Your full Name and Social Security Number is required to help verify your identity and process your Request. Failure to provide it may result in delays
and/or rejection of your request. This information is kept confidential in accordance with Federal and State laws and regulations.
Job Title and brief description of duties:
Home Address:
City/State/Zip:
Request Type:
New
Updated
Agency Name:
Signature:
Date:
TO BE COMPLETED BY AGENCY HR/LEAVE BANK COORDINATOR
Leave Bank Coordinator:
Email:
Phone #:
Fax #:
Last Date Employee Worked:
Leave Bank Membership Expiration Date**:
Hours Needed: __________ Hrs.
Dates to Cover: From
To
□
□
Can agency accommodate a modified duty assignment? Yes
No
□
□
Is employee on FMLA leave? Yes
No
If Yes, provide end date of current FMLA:
□
□
Has employee been on one-day sick slip restriction within the last two years? Yes
No
If Yes, provide effective date of restriction:
□
□
Has employee been disciplined within the last year? Yes
No
If Yes, provide effective date of disciplinary action:
□
□
Employee’s last performance evaluation rating was:
Satisfactory or Above
Less than Satisfactory
□
□
Is this absence due to an on-the-job injury? Yes
No
If Yes, Contact DBM Leave Bank Program Manager
□
□
Has the employee been seen by the State Medical Director? Yes
No
If Yes, Provide copy of Medical Report
□
□
Has the employee applied for Disability Retirement? Yes
No
If Yes, Provide copy of signed SRA 129
Leave Bank Coordinator’s Signature:
Date:
**COPY OF MOST CURRENT LEAVE BANK MEMBERSHIP FORM IS REQUIRED
COMPLETED BY APPOINTING AUTHORITY OR DESIGNEE
This employee has exhausted all forms of annual, sick, personal and compensatory time because of a serious and
prolonged medical condition. The employee has been a member of the Leave Bank for at least 90 days or has been
granted an exemption by the Secretary of Budget and Management. Approval will not cause the employee to exceed
2,080 hours of leave from the Leave Bank and Employee-to-Employee Leave Donation Programs during his/her entire
State employment. Approval will not cause the employee to exceed 16 months of continuous leave, when combined
with all other forms of paid leave. As the appointing authority for this employee, I have reviewed the employee’s
records and I certify that this request meets all of the criteria specified in this Section.
______________________________________________________________
______________________________________
Signature of Appointing Authority or Designee
Date
MS 408
(Rev. 6/2017)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business