OHR 325 (Revised 6-18) COMMITTEE
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 Healthcare Provider 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 Code:____________________________
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 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. If you are
receiving workers compensation, long-term disability payments, or both, you are not eligible to receive shared leave per WSU policy.
Shared leave will not be granted for common or minor illnesses, injuries, impairments or physical or mental conditions.
Describe and provide any necessary information that would help in concluding that the illness, injury, impairment or physical or
mental condition is serious, extreme, or life threatening:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Is this a work-related injury? ___________________
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 Worker’s Compensation or Long-Term Disability is ineligible for Shared Leave)
I certify that I understand, agree to and meet the requirements 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:____________________________
FORWARD COMPLETED FORM TO: Leave Administrator, Human Resources, Wichita State University,
1845 Fairmount St, Campus Box 15, Wichita KS 67260-0015 or Fax to 316-978-3201 or email to totalrewards@wichita.edu
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