OHR 325 (Revised 07-15) COMMITTEE
FORWARD COMPLETED FORM TO Lana Anthis, Wichita State University, Office of Human Resources,
Campus Box #15, Wichita KS 67260-0015 or Fax to: (316) 978-3201.
STATE OF KANSAS
SHARED LEAVE PROGRAM
Wichita State University
Shared Leave Request Form
When completing form please write legibly and be clear and thorough with explanations. A Certification of
Health Care Provider form and Confidentiality Waiver Form must also be completed for each new request or
request to extend shared leave.
To be completed by employee or employee’s representative
Name:
Employee myWSU id #:
Home Address:
(City) (State) (Zip)
Home Telephone:
Work Telephone
Department Name:
Supervisor’s Name:
Extension
Date of Employment:
Request is for: Self
Family Member
Name of Family Member and explanation of relationship (please include age if child):
Date illness/injury began:
Anticipated duration:
Estimate number of hours requested:
Date all paid leave will be exhausted:
Last day of work:
Shared leave will only be granted for serious, extreme, or life-threatening illnesses, injuries, impairments or physical or
mental conditions which have caused, or are likely to cause, the employee to take leave without pay or terminate
employment. Shared leave will not be granted for common or minor illnesses, injuries, impairments or physical or mental
conditions. To be eligible for consideration, an employee must not have a history of leave abuse within the last year, and
have a favorable recent evaluation.
Describe and provide any necessary information that would help in concluding that the illness, injury, impairment or
physical condition is serious, extreme or life-threatening:
Are you currently receiving Worker’s Compensation?
Are you currently receiving Long-Term Disability?
Have you applied for Worker’s Compensation? Date Applied:
Have you applied for Long-Term Disability? Date Applied:
(An employee receiving Workers’ Compensation or Long-Term Disability is ineligible for Shared Leave.)
I certify that I understand, agree to and meet the requirement and conditions of the shared leave program as authorized in
WSU policy. I authorize the appointing authority to obtain any necessary information regarding my request for shared
leave and to share that information with the Shared Leave Committee. I understand that denial of this application is not
subject to appeal. I declare under penalty of perjury that the foregoing is true and correct. Executed on date below.
Employee’s Signature: Date:
