Fillable CSCU Management/Confidential Professional Personnel (Northwestern Connecticut Community College)

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CSCU Management/Confidential Professional Personnel (Northwestern Connecticut Community College)

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APPLICATION FORM
CSCU Management/Confidential Professional
Personnel
SICK LEAVE BANK GRANT
Employee Name ____________________________________________Date _____________
College/University/System Office ____________________________________________
Job Title ____________________________________________________________________
(Employee must be in a non-temporary, full-time M/C position for at least one year.)
Instructions:
Part A – To be completed by the employee or employee’s representative and submitted to the
Human Resources Office when exhaustion of earned sick leave days has, or is likely, to occur.
Part B – To be completed by the Human Resources Office and submitted to the Sick Leave Bank
Committee as soon as possible after receipt. One copy to be retained by the Human Resources
Office.
Part C – Following the vote on the application, System Office to send a copy to the Human
Resources Office and retain the original in the System Office.
PART A
No. Days Requested
Statement of Justification (Please provide all necessary information to assist Committee)
List of all attachments (including adequate medical evidence)
1.
State of Connecticut (Form P-33A, Rev. 02/11) Medical Certificate signed by a physician.
2.
3.
_________________________________
Employee’s Signature Date
_________________________________
Signature of Employee’s Representative Relationship of Rep.to Employee
(Only if employee is incapacitated)
Name __________________________
PART B
. Employee has/will exhaust(ed) all earned sick leave on _________________________
Criteria met Returned to employee regarding the following:
__________________________________________ __________________
Signature of Human Resources Director/Officer Date
PART C
(For use by Sick Leave Bank Committee)
1. Application is accepted for initial grant of ______ days to be taken effective
_______________ ,but no later than ______________.
Application is rejected.
For the Committee Date
2. Application is accepted for an additional grant of ______ days to be taken no later
than ______________.
Application is rejected.
For the Committee Date
3. Application is accepted for an additional grant of ______ days to be taken no later
than ______________.
Application is rejected.
For the Committee Date
4. Application is accepted for an additional grant of ______ days to be taken no later
than ______________.
Application is rejected.
For the Committee Date
Name __________________________
PART D
(For use by Human Resource Office)
Total Days Granted _________________
Total Days Taken _________________
Total Days Returned to Sick Leave Bank _________________
Date Employee Returned to Work _________________
Human Resources Director/Officer Date
Revised 04-08-15
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CSCU ManagementConfidential Professional Personnel (Northwestern Connecticut Community College)

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Completed 7 September 2020

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