3.9WFF—SICK LEAVE BANK REQUEST FORM

PLEASE COMPLETE AND RETURN TO A SICK LEAVE BANK COMMITTEE MEMBER (BEFORE YOU ARE ABSENT AND THE PAYROLL DEDUCTION IS MADE).

Name ____________________________________ Home Phone ____________________________

Home Address___________________________________________________________________
Street City Zip

School building where you teach __________________ School phone __________________

Have you contributed time to the sick leave bank system? ____________________________

Briefly describe the nature of your disability or illness and the circumstances that caused you to make this request.

_______________________________________________________________________________________

_______________________________________________________________________________________

Number of sick leave days requested: _____

Beginning date _____________________ Ending date _____________________

Are you currently being treated by a physician? ____________________________________
Have you used all of your accumulated sick leave? _________________________________
How many days have you been absent this year due to illness or disability? ______________

___________________________________________
Signature

_______________________________________________
Date

____________________________________________________________________________________

COMMITTEE USE ONLY

Date considered: _____________________________ [ ] Approved [ ] Not Approved

Number of days credited: ______________________

______________________________________________
Committee Chairperson

Date Adopted: March 8, 2004
Last Revised: May 11, 2009
3.9.1WFF - SICK LEAVE BANK USE FORM

Applicant _______________________________ Date ____________________________

Address ________________________________ Home phone _____________________

School Building ___________________________ School phone ____________________

The committee that governs the use of the Sick Leave Pool has reviewed your application for additional sick leave days.

The committee has authorized that _____ days be credited to you from the Sick Leave Pool. The dates granted to you have been:

___________________________________________________________________________

This form has been sent to the Central Administration Office to notify them of the days granted.

_______________________________________
Chairperson of Committee

_______________________________________
Secretary of Committee

_______________________________________
Date Approved by Committee

The recipient must re-contribute one (1) day prior to September 15 to be eligible to make additional withdrawals.

Three copies are to be made of each application. They are to be sent to the applicant, Central Administration Office, and one to the Sick Leave Bank Committee.

Date Adopted: March 8, 2004
Last Revised: May 11, 2009