SICK LEAVE EXTENSION REQUEST
SECTION A – TO BE COMPLETED BY EMPLOYEE
Employee Name: Employee Number: _______________________
Job Title: _________________Department: ______________Home #___________ Cell #_____________
I am requesting a Sick Leave Extension (Available in 30-day increments), for the following period of time:
DATE OF EXTENSION TO BEGIN:
DATE OF EXTENSION TO EXPIRE:
My reason for requesting the extension is:
Sick Leave Extension: (1) First 30 Days (2) Second 30 Days (3) Third 30 Days
Please Note
1. Sick leave extensions are granted in 30-day increments, once an employee has exhausted all of their
accrued time.
2. An employee is allowed 3 sick leave extensions during period of employment with the city of providence.
3. All Sick Leave requests must be accompanied by a physician’s/medical note, stating time employee is
required to be out of work.
4. All Leaves are subject to approval by department directors as well as the director of Human Resources in
order to be granted.
I understand that if I take a position with another employer or become self-employed, I will be
terminated automatically.
Employee Signature Date
SECTION B - APPROVAL – TO BE COMPLETED BY EMPLOYER
Department Director Date
Director of Personnel Date
click to sign
signature
click to edit
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