Form Ssl - Application For Supplemental Sick Leave

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STATE OF NH
APPLICATION FOR SUPPLEMENTAL SICK LEAVE
Important: All fields of the application must be completed. An incomplete
application may lead to denial of your request for Supplemental Sick Leave.
Part I – to be completed by the employee or designee.
PLEASE PRINT OR TYPE – ALL FIELDS MUST BE COMPLETED
1.
1. Name:
2. Job Title:
2.
3. Agency:
4. Department/Division:
5. Are you covered by the SEA Bargaining
Unit?
Yes
No
6. Work Phone:
7. Home Phone:
8. Home Address:
9. Have you previously filed for SSL?
Yes
No
(a) If yes, when?
(a)___________Month
__________ Year
(b) For what condition was the leave
(b)________________
approved?
10. I am requesting _________ days of supplemental sick leave.
11. Is your injury or illness work-related?
Yes- Stop here, your application cannot be processed if your injury or illness is work related.
(Please note: In the event of a work-related medical condition, SSL would not be considered by the LMC
until the workers’ compensation process has been completed – please discuss with your Human
Resources representative.)
No- Please describe reason for request below.
12. Describe reason(s) for your request in detail. Please include the date of injury or commencement of
illness:
(a) Include information relative to your diagnosis, course of treatment, and why you cannot return
to work at this time.
(b) Identify whether your condition is ongoing or not.
SSL V3
Rev 8/4/2014

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