Editing previous response:

Please fix the highlighted areas below before submitting.

Request for Sick Leave Pool Days

Employee Name (Legal Name)*

Answer required for "Employee Name (Legal Name)"

Last 4 of Social Security*

Answer required for "Last 4 of Social Security"

Campus/Department

Answer required for "Campus/Department"

Position/Job Title

Answer required for "Position/Job Title"

_{Leave Duration}

Anticipated Leave Start Date*

Answer required for "Anticipated Leave Start Date"

Anticipated Return to Work Date

Answer required for "Anticipated Return to Work Date"

Answer Required

I have or will have used all my available paid leave, as well as any compensatory time and vacation days, as applicable.

_{Reason for Request}

Nature of Illness or Injury

Do not provide information about genetic tests, as defined in 29 C.F.R. § 1635.3(f), genetic services, as defined in 29 C.F.R. § 1635.3(e), or the manifestation of disease or disorder in the employee’s family members, 29 C.F.R. § 1635.3(b).

Answer required for "Nature of Illness or Injury"

Date of Illness or Injury

Answer required for "Date of Illness or Injury"

Date Physician consulted

Answer required for "Date Physician consulted"

Name, address and phone number of attending physician

Answer required for "Name, address and phone number of attending physician"

_{Hospital information (if applicable)}

Were you hospitalized?

Answer required for "Were you hospitalized?"

Yes

Name of Hospital

If you answered yes above, please complete the this information

Answer required for "Name of Hospital"

Hospital Begin Date

Answer required for "Hospital Begin Date"

Hospital End Date

Answer required for "Hospital End Date"

Employee Acknowledgment*

Answer required for "Employee Acknowledgment"

I certify that the information given on this request for sick leave pool is accurate and true.

Signature*

Signature Required

Approval

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"