Revised 11-15-2018
Employee Name (print): ____________________________________________
Employee Number: ________________________________________________
I hereby request participation in the City of Little Rock Catastrophic Leave Bank program. I agree to
contribute ______ hours (minimum of eight (8) for 40-hour employees; 24 for 56-hour employees)
from my personal accrual (mark one):
Sick Leave (SL) or Short-Term Disability (STD) accrual
Vacation (Vac) or Paid Time Off (PTO) accrual
[If left unmarked, the minimum hours will be taken from SL / STD.]
Upon implementation of the bank and on each plan anniversary date (January) until and unless I
provide notice in writing that I wish to cease participating, the amount indicated above will be
contributed to the bank annually. I understand that any leave contributed will belong to the bank and
cannot be restored to me even if I cease participation. After a request to cease participation, I
understand that I will continue to participate until the next plan anniversary date but after that date I
will not receive any benefit unless I complete a new enrollment and make the required contribution.
I also understand that any request for use of Catastrophic Leave requires the following:
1. Exhaustion of all accumulated leave.
2. An Absence of at least four weeks/twenty workdays before Catastrophic Leave can be granted
(includes time used in accordance with #1 above).
3. Specific documentation from an attending physician, including diagnosis, prognosis, projected
return to work date, and any anticipated restrictions on work activities as of that release date.
4. Approval by the Catastrophic Leave Bank Committee.
5. Completion of a request form with all required information and documentation.
6. Sufficient Catastrophic Leave Bank hours available for use.
7. I may have to supply documentation for previous sick leave usage and that the Committee may
contact my supervisor, department director and/or review my personnel file to determine if sick
leave abuse has occurred.
_______________________________ ____________________
Signature Date
Return completed form to Attention: Labor & Employee Relations Division via FAX# 501-244-5475
or email
Please call 501-371-4824 if you have any questions regarding completion of this form.