Catastrophic Illness Sick Leave Request Form printable pdf download

Catastrophic Illness/Sick Leave Request Form

The purpose of the Catastrophic Illness/Sick Leave Bank is to create a bank of sick leave days from which participants may apply for additional sick

leave when suffering from catastrophic illness or accident and have exhausted all other paid leave.

“Catastrophic illness” is defined to mean an illness or injury that is expected to incapacitate an employee for an extended period of time, and the

incapacity requires the employees to take time off from work for an extended period of time. An employee suffering from a catastrophic illness or

injury shall provide verification by means of a letter, dated and signed by the ill or injured person’s licensed physician of the State of California,

indicating the incapacitating nature and probable duration of illness or injury.

Only employees (or their agents) may apply to use the bank by submitting their request to the Sick Leave Bank Review Committee using the

appropriate District form. Included with the form will be verification of the catastrophic illness prepared, in writing, by a licensed physician of the

State of California.

The Sick Leave Bank Review Committee will consist of two (2) employees appointed by the Association and one (1) management representative appointed

by the District. The committee will review all applications. Approval of any request will require a majority vote of the committee. The decision of the

committee shall be final and binding. Within ten (10) duty days of receipt of employee application, the committee will notify, in writing, the applicant of

its decision. All applications submitted to the committee shall remain confidential.

An employee may request a maximum of twenty (20) days per application. At the end of the twenty (20) day period, an additional twenty (20) days

may be requested for a maximum of forty (40) days to be used per catastrophic event.

Days granted but not used will be returned to the bank. One (1) day used will be equal to one (1) day at the employee’s per diem rate of pay.

Leave granted under this agreement will be coordinated with the extended illness leave provision to create a full day of wages. The sick leave bank

will be debited one-half (1/2) day for each day used.

Leave from the bank may not be used for illness or disability that qualified the employee for workers’ compensation benefits.

When the Sick Leave Bank Review Committee reasonably presumes the applicant may be eligible for a disability award or retirement under STRS, the

committee may request the employee apply for disability or retirement benefits. Failure of the employee to submit a complete application within

twenty (20) days of the request shall disqualify the employee from further catastrophic leave bank payments.

Employee Name (print) _________________________________________________

Site __________________________________

Social Security # _______________________________________________

School Year ____________________________

Please complete the following:

Attached is a verification letter, dated and signed by the ill or injured person’s licensed physician of the State of California, indicating the

incapacitating nature and probable duration of illness or injury.

I am requesting ____________ days (maximum of twenty [20]) to be donated for this application period.

a. _________ This is my first application for this catastrophic illness.

b. _________ This is my second application requesting additional days for my catastrophic illness.

I am receiving Workers’ Compensation benefits for this illness.

_____________________________________________________________________

______________________________

Signature of

Employee or

Employee’s Agent

Date

Office Use Only

Sick Leave Balance ___________days

Is the employee in difference pay?

Yes

Is the employee receiving workers’ compensation benefits? Yes

Sick Leave Bank Review Committee Use

Committee Members: For the Association ______________________________________ _______________________________________

For the District

______________________________________

Approved for _____ donated days from the Catastrophic Sick Leave Bank. This is the employee’s

First allocation

Second allocation

Denied due to _____________________________________________________________________________________________________

_____________________________________________

_______________________________________

_________

For the Association

For the District

Date

Catastrophic Illness Sick Leave Request Form

Related Articles

Related forms

Related Categories