Sick to Family Illness Conversion Request Form
Use this form to notify payroll of your need to convert sick leave to additional family illness time. Refer to City policy or the applicable Collective Bargaining Agreement for information on how the conversion applies.
Request Information
Employee Name
*
First Name
Last Name
Employee Email
*
example@example.com
Supervisor Name
*
First Name
Last Name
Supervisor Email
*
example@example.com
Start Date of Leave
*
-
Month
-
Day
Year
Date
End Date of Leave (if multi-day request)
-
Month
-
Day
Year
Date
Family Illness Hours Needed
*
Brief Description (Do not include detailed medical information)
*
Submit
Should be Empty: