Sick Bank Leave Request Form

Sick Bank Leave Request Form

This form is to request sick bank leave for major medical emergencies which makes and employee unable to perform any work, including light-duty work. It may also be used to care for a dependent who is experiencing a major medical event and requires the care of the employee such that they cannot perform their normal duties as required. This request will be reviewed by a sick bank committee for approval and will require a doctor's note describing the condition(s), and that no work will be able to be performed as a result of the condition(s).
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Primary Place of Employment*
Describe the circumstances leading to the need for sick bank leave:*
How many days are you requesting for this event (the maximum is 60 days):*
If care is for a dependent, select thier relationship to you:
Doctor's Name*

First NameLast Name
Doctor's Contact*
Please enter a valid phone number.
Certification and Authorization:
I certify that the information provided in this request is true and accurate to the best of my knowledge. I understand that approval of sick bank leave is subject to review and discretion by the Sick Bank Committee. I authorize the District to contact the doctor listed above regarding my medical condition for verification purposes. I also authorize the District to discuss my, or my dependent(s), condition with necessary personnel, including peers on the Sick Bank Committee, to process my sick bank leave request.
Signature*

Clear
Should be Empty: