Application for Extended Sick Leave must be accompanied by a medical practitioner's certificate supporting the application. The Board reserves the right to refer a teacher applying for Extended Sick Leave to the Board's Medical Officer.
Application for Extended Sick Leave. Appendix D Revised: 8-22-2016 Employee’s Name: Date of Birth: Building: Assignment: First work day lost due to THIS disability: Nature of Medical Disability: Employee's Signature Date of Application VERIFICATION BY PHYSICIAN I have examined the above named employee of the Kalkaska Public Schools and I verify that for medical reasons, he/she is unable to work. Date approved to return to work (if known): Physician's Signature Date ********************************************************************************* For Office Use Only ********************************************************************************* Employee’s Year of Service ESL Scale LTD Eligibility Day Days Approved Date returned to work Approval Master Teacher Incentive Program Appendix E Revised: 8-22-2016
Application for Extended Sick Leave. When it become apparent that an employee will be exhausting his/her accumulation of unused sick leave days, the employee or his/her department head shall immediately notify the Personnel Office. An "Extended Sick Leave Application" shall then be sent to the employee for his/ her physician to complete. The completed "Extended Sick Leave Application" must be returned to the Personnel Office prior to the expiration of the employee's accumulation of unused sick leave days so that it can be processed and so that a determination as to eligibility can be made. In the event that the completed "Extended Sick Leave Application" is not returned to the Personnel Office prior to the expiration of an employee's accumulation of unused sick leave days, the employee shall be placed on leave without pay until the completed "Extended Sick Leave Application" is received by the Personnel Office and a determination is made. If, in such a instance, it is determined that an employee is eligible to receive extended sick leave payments, the employee would then be reimbursed retroactively to the date he/she was first placed on a leave without pay.
Application for Extended Sick Leave. Appendix D Revised: 8-22-2016 First work day lost due to THIS disability: Nature of Medical Disability: Employee's Signature Date of Application VERIFICATION BY PHYSICIAN I have examined the above named employee of the Kalkaska Public Schools and I verify that for medical reasons, he/she is unable to work. Date approved to return to work (if known): Physician's Signature Date ********************************************************************************* For Office Use Only ********************************************************************************* Employee’s Year of Service ESL Scale LTD Eligibility Day Days Approved Xxxx returned to work Approval Master Teacher Incentive Program Appendix E Revised: 8-22-2016
Application for Extended Sick Leave. APPENDIX D Revised: 8-22-2016 Employee’s Name: Date of Birth: Building: Assignment: First work day lost due to THIS disability: Description of the nature of medical disability: Employee's Signature Date of Application VERIFICATION BY PHYSICIAN I have examined the above named employee of the Kalkaska Public Schools and I verify that for medical reasons, he/she/they is/are unable to work. Physician's Signature Date DATE EMPLOYEE IS ELIGIBLE TO RETURN TO WORK: *************************************************************************** *** For Office Use Only
Application for Extended Sick Leave. APPENDIX D Revised: 8-22-2016 Employee’s Name: Date of Birth: Building: Assignment: First work day lost due to THIS disability: Nature of Medical Disability: Employee's Signature Date of Application VERIFICATION BY PHYSICIAN I have examined the above named employee of the Kalkaska Public Schools and I verify that for medical reasons, he/she is unable to work. Date approved to return to work (if known): Physician's Signature Date ****************************************************************************** *** For Office Use Only
