Leave Pool Withdrawal Form
05/01/2012
page 1 of 1
Crisis Leave Pool Withdrawal Form
Employee Name
CWID
Home Phone#
Date
I am requesting hours of Crisis Leave (240 hour limit per calendar year) for the following dates:
(start date) to (end date).
Employee was absent from work due to this condition beginning on:
Employee exhausted all accrued comp. time, vacation and sick leave as of (date)
Reason for Crisis Leave Request: (Please check one)
Employee's Condition
Care for eligible family member
Relationship:
Child Spouse
Parent
Other: __________________________
_______________________________________________________
________________________________
Employee signature
Date
This crisis leave request form must be submitted to the Leave Pool Manager, Human Resources Department.
Requests should be made at least 10 days before the crisis leave is needed.
The Leave Pool Manager will contact you within 5 work days about the status of the request.
______________________________________________________
________________________________
Approval by Leave Pool Manager
Date
Human Resources Department
INSTRUCTIONS: This form is used by employees, in addition to the Attending Physician Certification (FMLA), to request
hours from the Crisis Leave Pool. This form must be submitted in a timely manner. BPCC regulations prohibit retroactive pay
from the Crisis Leave Pool. Crisis leave will not be credited to the employee until all paperwork is received and approved.
Crisis leave is not available for use with Worker's Compensation Benefits.
FMLA Paperwork on file with Human Resources -(or
attached to this request):
Yes
No
Alternate Phone#
Disapproval by Leave Pool Manager
______________________________________________________
I (or family member/relation) have a crisis situation that may qualify for crisis leave as confirmed by the attached Family Medical
Leave Act (FMLA) form which includes: physician's certificate which provides information about the patient's condition, nature of
illness/injury, and relevant medical history, type of treatment prescribed, prognosis, and the ability to return to work. I undertand that
the value of annual leave granted as crisis leave cannot exceed 75% of my pay in a regular work week and that I will not accrue
leave while using crisis leave.
Mailing Address
