8.6WFF—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.

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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? \_\_\_\_\_\_\_\_\_\_\_\_\_\_

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Signature

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Date

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COMMITTEE USE ONLY

Date considered: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \[ \] Approved \[ \] Not Approved

Number of days credited: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Committee Chairperson

Date Adopted: June 12, 2024
Last Revised: