APPLICATION FOR USE OF SICK LEAVE POOL CREDITS
(Please Fill in on Screen and Print - Forward to Human Resources, 20E)
Last Name: _____________________________ First Name: _____________________________ Middle Initial: _______
Home Address: ___________________________________________________________________________________
UWF ID Number: ____________________________ Phone Number: __________________________
Contact Person and Phone Number, If Other Than Employee: ______________________________________________
Length of Time Requested From: ______________________ To: _______________________ Hours Requested: _______
Explanation of Request:
EACH APPLICATION MUST INCLUDE A COMPLETED ATTENDING PHYSICIAN'S STATEMENT
Is there any disability insurance benefit covering this illness? Yes No
If yes, provide name of Insurance Provider, type, and amount of coverage.
I certify that all information provided in support of this application is complete and true to the best of my knowledge. I
understand that the Committee will review information of a confidential nature in order to determine my request. I
acknowledge that upon the filing of my request, the Committee will receive and may obtain the necessary medical
information from my physician(s). The Committee may base its determination on my physician's statement and any other
information deemed relevant by the Committee in making its decision.
_________________________________________________ ___________________________________
Applicant Signature Date
To be completed by Sick Pool Administrator
Requestor is currently an active participant in the Sick Leave Pool.
Requestor has, or will have, depleted all personal annual, compensatory, and sick leave credits.
Received completed Attending Physician’s Statement.
Has sick leave benefit to be authorized been coordinated with applicable disability insurance coverage?
Total Sick Leave Pool credits authorized in the last 12 months.
To be completed by Sick Pool Administrator
Approved Length of Time: From: ________________ To: ________________
Disapproved Total Sick Leave Hours Approved: ___________________
