Sick Leave Pool Membership Application (Procedure 2.2100 Form)
Seminole State College Sick Leave Pool
I am formally requesting membership in the Seminole State College sick leave pool. I understand that:
- Upon acceptance for membership, fifteen (15) hours of my personal sick leave will be deducted from my personal sick leave balance and contributed to the sick leave pool. I will not have to make an additional contribution of personal sick leave unless the pool balance is reduced below 450 hours; in that case, an additional contribution of 7.5 hours will be deducted from my personal sick leave balance. However, I will not be required to contribute more than 7.5 hours in any one fiscal year. Further, I understand that this additional deduction will occur automatically unless I inform the Director of Human Resources, in writing, within ten work days of the date I am notified of the need for an additional contribution, of my wish to discontinue membership.
- A maximum of 225 hours or 30 days of sick leave per fiscal year may be granted to me from the sick leave pool if I become catastrophically ill or injured and have exhausted all of my personal sick leave. My request for leave from the sick leave pool must be made in writing to the Sick Leave Pool Advisory Board by me or my authorized representative. I understand that I may request up to an additional 225 hours (30 days) from the sick leave pool per fiscal year if required due to the severity of the illness, accident, or injury. The maximum number of days of leave which may be drawn from the sick leave pool in any one fiscal year is 60 days.
- Any request to use leave from the sick leave pool is subject to review by the Human Resources Office and approval of the President. The Advisory Board may request additional information in connection with a request for leave, and approval of any request may be conditioned upon the receipt of medical or other information.
- The Sick Leave Pool Advisory Board is authorized to make recommendations regarding membership and administration of the sick leave pool. Any misrepresentation or misuse of the sick leave pool may subject me to disciplinary action. Personnel information obtained by the Advisory Board is confidential.
- My participation in the pool is at all times voluntary, and I may request in writing, at any time, that my membership be canceled. I understand that any hours of my personal sick leave which have been contributed to the sick leave pool will remain in the pool upon cancellation of membership or termination of employment.
Please complete the following:
| Name: | Last: |
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First: |
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M.I. |
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| Social Security Number: |
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| Campus Address: |
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Department: |
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| Phone No./Work: |
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Home Phone: |
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| Employee's Signature: |
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Date: |
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To be completed by the Human Resources office.
Your application is:
Approved.
I certify that, as of / / , the above individual has hours of sick leave and has been employed with Seminole State College for at least one year and that sick leave hours have been deducted from his or her balance and contributed to Seminole State College's sick leave pool.
Disapproved.
Your application is disapproved because:
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| Director, Human Resources | Date |