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Request for Sick Leave Pool Days

Employee Name (Legal Name)*

Answer Required

Last 4 of Social Security*

Answer Required

Campus/Department

Answer Required

Position/Job Title

Answer Required

_{Leave Duration}

Anticipated Leave Start Date*

Answer Required

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

Date of Illness or Injury

Answer Required

Date Physician consulted

Answer Required

Name, address and phone number of attending physician

Answer Required

_{Hospital information (if applicable)}

Were you hospitalized?

Answer Required

Yes

Name of Hospital

If you answered yes above, please complete the this information

Answer Required

Hospital Begin Date

Answer Required

Hospital End Date

Answer Required

Employee Acknowledgment*

Answer Required

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

Signature*

Signature Required

For HR Department Use Only		For Business Office Use Only
Date Received:		Enrollment Date:
Employee Notified Date:
	▢ Granted ▢ Denied

Confirmation Email

Confirmation Email *

Email Required