Sick Leave Request to Withdraw Form (Procedure 2.2100)

Please complete the following:

Last Name:____________________________ First:____________________________ MI.: ____________ 

Address:__________________________________________________

City:____________________________ State: _____ Zip Code:and__________

Phone Number: ( )____________________________ Social Security No:____________________________

Job Title:____________________________ Department:____________________________

Description of Accident/Illness and/or Injury: _________________________________________________________________

_________________________________________________________________

Current Treatment:____________________________

Hours Requested from Sick Leave Pool:____________________________

Name of Medical Provider:____________________________

Address:____________________________

City:____________________________ State: ________ Zip Code:_________________

Phone Number: ( )____________________________

I HEREBY CERTIFY that the above information is true and correct to the best of my knowledge. I hereby acknowledge that the Advisory Board may request additional information from the above-listed medical provider and agree to provide an Authorization for Release of Medical Records upon request for the above medical condition. I understand that my leave may be terminated upon a determination that the requirements for leave are no longer met. I further understand that any alleged abuse of the Sick Leave Pool shall be investigated and upon a finding of wrongdoing, I will be required to repay all hours drawn and am subject to such other disciplinary action as is determined by the Board of Trustees.

 

DATE _____________________ EMPLOYEE SIGNATURE____________________________

To be completed by the Human Resource Office

I HEREBY CERTIFY that this employee is a member of the Sick Leave Pool of Seminole State College and has an earned sick leave balance of___________ hours as of this date.

 

DATE ______________________ HUMAN RESOURCE OFFICER______________________

        THIS REQUEST IS HEREBY GRANTED FOR ______________________

         THIS REQUEST IS HEREBY DENIED ______________________

 

DATE ______________________ SICK LEAVE POOL ADVISORY ______________________