Sick Bank Leave Request Form

Sick Bank Leave Request Form

Only employees who have donated to the bank are eligible to request sick leave from the pool.
Employee Name*

First NameLast Name
Rank/Title*
Department*
WIU ID*
Office Phone*
Please enter a valid phone number.
WIU Email*
example@example.com
Campus Address*
Percent Appointment*
Start Date*

MonthDayYear
Date
An employee who is a member of the Voluntary Sick Leave Bank may request sick leave (maximum of twenty working days) from the pool after exhausting accumulated leave. Leave may be requested and used only for catastrophic personal illness or injury of the employee or to care for a parent, spouse, domestic partner, or child with a serious health condition as stipulated under the Family and Medical Leave Act (FMLA). A licensed medical practitioner's statement describing the severity of the illness or injury, the diagnosis, the date it began, and probable duration must be included with this request.

I hereby request approval of the following Sick Leave Bank usage:
Number of Days Requested*
Beginning Date of Leave*

MonthDayYear
Date
Reason for Request*
Name of person experiencing catastrophic illness or injury and relationship to the employee
Signature

Clear
Should be Empty: