Form Ssl - Application For Supplemental Sick Leave Page 6
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6STATE OF NH
APPLICATION FOR SUPPLEMENTAL SICK LEAVE
11. I recommend approval of the request:
Yes
No
(a) If yes, how many days?
(Please calculate anticipated accruals in this
___________days
amount.)
12. If RECOMMENDED IN PART or NOT RECOMMENDED, describe reason(s) below or on a separate
sheet.
Your recommendation is confidential and should not be shared with the requesting employee. Please
return this form directly to the Bureau of Employee Relations, Division of Personnel.
13. APPOINTING AUTHORITY OR DESIGNEE
Name:
________________________________________
Title: _________________________________
(Please print)
________________________________________
Date: ________________________________
(Signature)
14. HUMAN RESOURCES
Name: _________________________________________
Title: ________________________________
(Please Print)
__________________________________________
Date: _______________________________
(Signature)
SSL V3
Rev 8/4/2014
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