1. 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:

 

 

Form AD-007/02 (1/2021)
 

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