Shared Sick Leave Request Form
Shared Sick Leave Request Form
Employee Name: |
Banner ID No.: |
| Department: | Contact Phone Number: |
| Number of Hours Requested: | Email address: |
| Reason for Request (Attach appropriate documentation from medical provider including description of injury or illness, date of onset or initial diagnosis, prognosis and anticipated date of return to duty): | |
I certify that I have read the College’s Shared Sick Leave Program Policy and understand my rights as outlined in the policy. I agree to abide by the procedures and conditions outlined in the policy. I understand that I must submit this form with the required medical documentation before this request can be considered.
Employee’s Signature Date
Request Form must be submitted to
Human Resources – Attention: Shared Leave Pool Manager
in an envelope or via email marked “Confidential.”
Shared Leave Pool Committee Action |
|||
| Approved: | Denied: | If approved, number of hours granted: | |
| If denied, reason for denial:
| |||
| Shared Leave Pool Manager Signature: | Effective Date of Action: | ||