Request for Sick Leave/Time Part-time Instructors
PT Instructor Sick Time Request form updated with routing revision info.docx
Revised: 2016-11-07
Please complete this form after each absence(s) from your scheduled class(es), and submit to your
Department Chair for review/approval.
PT Instructor’s Name: _____________________________ COCC ID #:
Department: ______________________________ Month of:
# of Sick Time Hrs Banked/Available this month: Hrs. Requested:
Instructor Signature: _______________________________ Date:
Dept. Chair Signature: _______________________________ Date:
Please send this form and any associated Supplemental NOAs to the appropriate Instructional Dean.
For Payroll Use, Only
Sick Time Hours Processed:
Course
(CRN)
missed
First
absence
this
term?
(Y/N)
Date(s)
Missed
Hours
Missed
Absence for
self or family
member
(indicate which by
relationship)
Name of Sub
(Dept. use only)
Hours Sub
paid
(Dept. use
only)
click to sign
signature
click to edit
click to sign
signature
click to edit
Eligibility/Procedure:
1. First Class Missed: Part-time non-benefited instructors may be absent one class session per course each term due to
illness without reduction in salary, but with reduction in mileage pay if applicable. Mileage pay will be reduced by the
appropriate amount considering the number of days not actually driven (per IRS guidelines). This benefit for part-time
instructors does not accrue from term to term.
2. Classes Missed Beyond the First: If additional classes are missed beyond the “first class missed” due to illness or
other qualified reasons during the term, the following will apply:
The part-time instructor will be paid for any additional classes missed up to the amount of accrued Sick Time
hours available for that month, with a reduction in mileage pay if applicable.
Any absence in excess of the accrued balance of sick time hours will result in a revised contract to reduce the
hours paid along with a reduction in mileage. Under those circumstances, part-time instructors missing a class
will have their NOA adjusted for short-term illness (5 hours or less) at $25/hour and long-term illness (over 5
hours) would be deducted at a percentage of the load for that class using the following formula: (Sick Hrs
requested beyond available balance) x (Step Rate/26.67)= Revision Amount.
Department Chairs must ensure that these changes are correctly indicated on the NOAs. It is the responsibility of each
Department Chair and Administrative Assistant to track the absenteeism of part-time instructors and to document it with
the appropriate form located on the HR forms page. A copy of the completed form must be filled out for each absence.
Once complete, forward the sick time request to the Instructional Deans’ offices for approval and processing along with
any supplemental NOAs completed for substitute part-time instructors covering classes. The Deans’ office will be
responsible for tracking absenteeism across campus for part-time instructors.
Sick Time Accrual: This benefit for part-time instructors accrues from term to term up to a maximum of 40 hours per
calendar year, and up to 40 hours per calendar year may “roll over” into the next calendar year up to a maximum of 80
hours of accrued sick time. This sick time is not paid out when part-time instructors employment with the college ends.
Eligibility and Approved Uses of Accrued Sick Time: (Contact HR, Ext. 7216, for verification or with questions)
Who qualifies as a Family Member? In addition to using accrued sick time for the part-time instructors own serious
health condition or other covered reasons (below), absences to care for the following family members’ needs are also
permissible and paid through this benefit: Spouse or domestic partner; parent (including biological, step, foster,
adoptive, custodial parents or in loco parentis); child (including biological, step, foster, adopted); employee’s or
spouse’s/domestic partners’ grandparents or grandchildren If the absence is for three or more consecutive scheduled
workdays, documentation will be required from a health care provider of the need for leave.
For what purposes may sick time be used? Employees are entitled to use sick time for the following purposes:
For an employee’s or family member’s mental or physical illness, injury or health condition or need for medical
diagnosis of these conditions or need for preventive medical care.
To care for an infant or newly adopted child under 18, or for a newly placed foster child under 18, or for a child
over 18 if the child is incapable of self-care because of mental or physical disability. To care for a family member
with a serious health condition.
To recover from or seek treatment for a serious health condition that renders the employee unable to perform at
least one of the essential functions of the employee’s job.
To care for a child of the employee who is suffering from a non-serious illness, injury or condition.
To deal with the death of a family member by attending the funeral or alternative, making arrangements
necessitated by the death of a family member, or grieving the death of a family member.
To seek legal or law enforcement assistance or remedies to ensure the health and safety of the employee or the
employee’s minor child or dependent for proceedings related to domestic violence, harassment, sexual assault, or
stalking.
To seek medical treatment, recover from injuries, or obtain services related to domestic violence, sexual assault,
harassment or stalking incidents to the employee or employee’s minor child or dependent.
For certain public health emergencies.
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