Fillable Central Connecticut State University - SUOAF SLB Application for Sick Leave Bank Loan

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Central Connecticut State University - SUOAF SLB Application for Sick Leave Bank Loan

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APPLICATION FORM
SUOAF Member
SICK LEAVE BANK GRANT
Member Name _____________________________________ Date _____________________
University/System Office _____________________________________________________
(Member - please check all applicable boxes)
SERS (TIER I, II, IIA) Participant OR ARP Participant
SUOAF member prior to OR SUOAF member on or after
July 1, 2001 July 1, 2001
NOTE: Employees hired prior to 7/1/01 who are not participating in ARP are
entitled to 120 days per occurrence.
Employees participating in ARP and/or employees hired on or after
7/1/01 may receive grants up to 120 days per occurence, but no more than
a lifetime total of 180 days.
Instructions:
Part A – To be completed by member or member’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.
Signature of Member Date
Signature of Member’s Representative Relationship of Rep.to Member
(Only if member is incapacitated)
PART B
ARP participant has been informed of their Long-Term Disability benefits as noted in the
SUOAF contract Article 30.3.3. on ______________________________.
Member has used ______________________ sick leave bank days during lifetime to date.
Member has/will exhaust(ed) all earned sick leave on _______________________.
Member has/will used up to a maximum of thirty (30) days of vacation time (if
accumulated) immediately preceeding eligiblity on ____________________.
Is there any evidence of abuse of sick leave usage by the member? Yes No
Criteria met Returned to employee regarding the following:
Signature of Date
Chief Human Resources Officer
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
PART D
(For use by Human Resource Office)
Total Days Granted _________________
Total Days Taken _________________
Total Days Returned to Sick Leave Bank _________________
Date Member Returned to Work _________________
Chief Human Resources Officer Date
Revised 04/15/15
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Central Connecticut State University - SUOAF SLB Application for Sick Leave Bank Loan

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Completed 27 May 2020

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