Sick Leave Bank Contribution Form. 1. NAME STAFF ID NUMBER
2. SCHOOL Check one: New Member of Sick Leave Bank (2 sick days) I understand that by affixing my signature below I state that I have read and agree to abide by the Rules and Regulations contained in the Sick Leave Bank, and I authorize the deduction of the specified sick leave days from my personal accumulation of sick leave days in this Corporation. I further understand that these days will be placed in the Sick Leave Bank. It is understood that, if any of the above information is believed to be incorrect by the Office of the Superintendent, the contributing teacher shall be notified by the Superintendent’s Office so that the proper corrections may be made. Signature Date =============FOR OFFICE USE============ Number of days contributed to the Sick Leave Bank Total remaining sick leave days Xxxxxxxx Southeastern Schools Sick Leave Bank Request Form Applicant: Please complete Section A. Please print legibly or type. Date: Name: Employee Number: School/Department: Telephone Number: Home Mailing Address: Street City Zip Have you submitted a Request for Leave to your principal/supervisor? YES NO Describe your illness, accident, or injury: Dates you are requesting to be paid from the Bank: From through
Sick Leave Bank Contribution Form. 1. NAME STAFF ID NUMBER 2. SCHOOL _ Check one: New Member of Sick Leave Bank (2 sick days) I understand that by affixing my signature below I state that I have read and agree to abide by the Rules and Regulations contained in the Sick Leave Bank, and I authorize the deduction of the specified sick leave days from my personal accumulation of sick leave days in this School Corporation. I further understand that these days will be placed in the Sick Leave Bank. It is understood that, if any of the above information is believed to be incorrect by the Office of the Superintendent, the contributing teacher shall be notified by the Superintendent’s Office so that the proper corrections may be made. Signature Date =============FOR OFFICE USE============ Number of days contributed to the Sick Leave Bank Total remaining sick leave days Xxxxxxxx Southeastern Schools Sick Leave Bank Request Form Applicant: Please complete Section A. Please print legibly or type. Date: Name: Employee Number: School/Department: Telephone Number: Home Mailing Address: Street City Zip Have you submitted a Request for Leave to your principal/supervisor? YES NO Describe your illness, accident, or injury: Dates you are requesting to be paid from the Bank: From through
1. The Sick Leave Bank is designed to ease the financial impact of members with a serious illness, accident, or injury that causes absence from work for an extended period of time. Serious illness is defined as being hospitalized, homebound under psychiatric care, temporarily totally physically disabled, and/or not able to perform the majority of essential daily living activities. Do any of these apply to your medical condition? YES NO
2. Is the injury and work missed due to an automobile accident covered under an automobile insurance policy? YES NO
3. After the employee has used all accrued sick leave, and upon approval of the request by the Sick Leave Bank Committee, withdrawal of days may occur. Have you used all your sick leave? YES NO
4. When a member is notified of eligibility for benefits under a disability plan and applies for the same within twenty (20) work days, Sick Leave Bank shall continue until such benefits begin, subject to the maximum of ninety (90) days per school year. If the employee does not apply for disability benefits, Sick Leave Bank benefits shall ease as of the twenty-first (21st) day.
Sick Leave Bank Contribution Form. 28 SICK LEAVE BANK MEMBER’S REQUEST FOR CONSIDERATION ........ 29 SICK LEAVE BANK MEMBER’S REQUEST FOR EXTENSION OF LEAVE 30
Sick Leave Bank Contribution Form. NAME _____________________________________________ STAFF ID NUMBER __________________
