Fillable Application to Receive Leave Under the Catastrophic Sick (City University of New York)

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Application to Receive Leave Under the Catastrophic Sick (City University of New York)

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Office of Human Resources Management
University Benefits Office
395 Hudson Street 5
th
Floor
New York, New York 10014
Tel: 646-664-3357
Fax: 646-664-3418
Application to Receive Leave Under the Catastrophic Sick Leave Bank Program
This applic
ation is to be completed by individuals who are employed full-time on an annual salary
basis, who are currently enrolled in the Catastrophic Sick Leave Program, with at least two (2) years
of continuous full-time CUNY service, who meet all the eligibility criteria (see Program details) to
receive donated leave through the Catastrophic Sick Leave Bank (“CSLB”). The applicant completes
Section I of this form and submits it to the College Office of Human Resources for verification. The
College Office of Human Resources completes Section II and forwards it to the University Benefits
Office if the employee is deemed eligible or returns the application to the employee if the employee is
deemed ineligible. The University Benefits Office completes Section III and returns it to the College
Office of Human Resources, which completes the attached letter and sends it to the applicant.
I. To Be Completed by the Employee
Name: __________________________________________________________
Home A
ddress: ___________________________________________________
CUNYfirst ID:* _____________________________________________________
Title: ____________________________________________________________
College/Department: ______________________________________________________
* If you don’t know your CUNYfirst ID, please contact your College Office of Human Resources.
1. Are you currently a member of the Catastrophic Sick Leave Bank?
Yes
No
2.
Is your illness or injury job related? Yes
No
3. How many
consecutive working days have you been absent from work due to your present
illness or injury? Please indicate the last date you were at work.
Number of Work Days Absent: ________
Last Date Worked: _________
4.
Have you applied for a sick leave advance from your college and/or for supplemental income
benefits from your union for your present illness? Yes No
If yes, please specify:
5.
Have you exhausted all of your annual leave, sick leave, compensatory time balances, and
sick leave advancements, t
o the extent applicable? Yes No
If no, please indicate the number of hours of leave remaining.
Annual Leave: ________
Sick Leave: ________
Compensatory Time: ________
Sick Leave Advancement
: ________
6.
Taking into account all of your annual leave, sick leave,
compensatory time balance, and sick
leave advancements, to the extent applicable, state the last date through which you will be, or
were, entitled to paid leave. Last date of paid leave entitlement:
7.
Please confirm that you have attached documentation from your physician stating the nature
and severity of your illness or injury and the projected period of your absence from work by
checking the box below.
Documentation Attached (Required) Absence Projected Through
______________________________________________________
8.
Are you currently on a disciplinary suspension and/or have you been subjected to a
disciplinary suspension during the l
ast 12-month period? Yes No
I hereby author
ize the University Benefits Office or CUNY’s Appeals Panel (should an appeal become
necessary) -- or a physician retained by either of them -- to contact my personal physician to seek
clarification or additional information concerning the medical documentation submitted herewith. I also
agree to submit to an examination by a physician retained by the University Benefits Office, if deemed
necessary. I understand that leave under the CSLB may be approved by the University Benefits
Office in increments not to exceed one (1) month. Should I need more than one (1) month of leave
under the CSLB, I understand that I may be required to submit additional medical documentation for
each subsequent one (1) month period, up to a maximum of ninety (90) days or three (3) months of
paid leave.
Employee Si
gnature: ____________________________________ Date: ______________________
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II. To be complet
ed by the College Human Resources Director or Designee.
Date the appli
cation was received by the College Office of Human Resources: ____________
A. Employee is eligible to receive leave through the Catastrophic Sick Leave Bank.
If Box “A
” is checked, the application is to be forwarded to the University Benefits Office with medical
documentation attached to the address below, within five (5) working days of receipt, from the
employee, to the extent feasible. See Section III below.
B. Employee is ineligible to receive leave through the Catastrophic Sick Leave Bank because:
Employee is not in a full-time eligible title employed on an annual salary basis.
Employee is in a substitute title with no underlying regular full-time annual appointment.
Employee does not have the minimum number of years of continuous full time service
with CUNY. Faculty members -- other than faculty Librarians -- must have five (5) or more
years of full-time continuous CUNY service. All other employees must have two (2) or
more years of full-time continuous CUNY service.
Employee did not donate at least one (1) day of sick leave or annual leave for the program
year in which leave has been requested. Faculty members -- other than faculty Librarians
-- are required to donate sick leave in order to participate in the CSLB.
Employee has previously exhausted his/her CSLB allotment for the current program year.
If Box “B
” is checked, the application is to be returned to the employee within five working days of
receipt, to the extent feasible.
You may appeal in w
riting and submit additional medical documentation, if any, to CUNY’s Appeals
Panel within fifteen (15) working days of your receipt of this denial. All decisions issued by CUNY’s
Appeals Panel shall be final and will not be subject to any further appeal by way of employee
collective bargaining agreements or otherwise.
Appeals are t
o be submitted in care of
the Office of the Vice Chancellor for Human Resources
Management, 205 East 42nd
Street, 10
th
floor, New York, New York 10017.
Signatur
e of College Human Resources Director or Designee:
Name (Pri
nt) ___________________________________________
Signature ______________________________________________ Date __________________
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III. To be compl
eted by the University Benefits Office
Date the appl
ication was received by the University Benefits Office: _______________________
Employee’s application to receive leave through the Catastrophic Sick Leave Bank is approved.
____________ Days approved.
Employee’s application to receive leave through the Catastrophic Sick Leave Bank is denied
because:
_____________________________________________________________________
Name (Print) ___________________________________________
Signature ______________________________________________ Date __________________
Th
e application is to be returned to the College Human Resources Director within five (5) working
days of the determination, to the extent feasible.
The College Human Resources Director will notify the employee of the determination and the appeals
process, as set forth in the attached letter.
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Notice to Employee for Request to Receive Catastrophic Sick Leave
Dear ______________________________:
Your request to receive leave through the Catastrophic Sick Leave Bank has been approved for
________ days.
Your request to receive leave through the Catastrophic Sick Leave Bank has been denied
because:
You may
appeal in writing and submit additional medical documentation, if any, to CUNY’s Appeals
Panel within fifteen (15) working days of your receipt of this denial. All decisions issued by CUNY’s
Appeals Panel shall be final and will not be subject to any further appeal by way of employee
collective bargaining agreements or otherwise.
Appeals ar
e to be submitted in care of
the Office of the Vice Chancellor for Human Resources
Management, 205 East 42nd
Street, 10
th
floor, New York, New York 10017.
College Human Resources Director or Designee:
Signat
ure _______________________________
Date: ________________________________
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Application to Receive Leave Under the Catastrophic Sick (City University of New York)

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Completed 18 December 2020

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