Fill - Free fillable - Sick Leave Pool Form (Little Priest Tribal College) PDF form

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OfficeofHumanResources

 SickLeavePool/DonationForm

Name:_____________ ____________________________ EmployeeID#__________________________________

Department:___________________________________ Phone#_______________________________________

JobTitle:____________________________________________________________________ ______________________

DONATION:Iwishtocontribute_________#ofhoursofsickleavetimetotheSickLeavePool.

Note:ReviewLPTCPoliciesandProceduresManualArticle13.10#4SickLeavePool,participationisavailableforregul ar 

full‐timeemployee swhohaveworkedcontinuouslyforLPTCforoneyear.Employeeswishingtodonatemusthave

accruedmorethantendaysofsickleaveandcannotdonateanamountthatwouldreducetheirsickleavebalancetoless

thantendays.

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InMakingthisdonationIunderstandthat

itis:

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1. Strictlyvoluntary,

2. ForusebyanyeligibleemployeeandImaynotstipulatewhomayreceivethisdonationand,

3. Nolongermypropertyrightandthatmysickleavebalancewillbereducedbyacorrespondingamount.

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WITHDRAWAL:IamrequestingtimefromtheSickLeavePool.*IunderstandthatImustmeetthe

followingconditions:



1. Ihavesufferedacatastrophicillnessorinjury.Itisasevereconditionaffectingmymentalorphysicalhealth

and,

2. Iwillabsentfromworkformorethantwoweeks

or10consecutivebusinessdaysand,

3. Iamlimitedtoamaximumof40business daysofdonatedleaveand,

4. Iwillhaveexhaustedallleaveentitlementand,

5. Ihaveattachedastatementfromalicensedpractitionersupportingstatements1and2.

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*IfitisdeterminedatalaterdatethatyouwereineligibletoreceivebenefitsfromtheSickLeavePool,thebenefitspaidtoyoumustberepaid

tothePool.

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Firstdayunabletoworkbecauseofillness/injury:_________________________________________________________

Dateallpaidleaveexhausted:_________________________________________________ ________________________

Dateyouwillreturntowork:__________________________________________________________________________

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_____________________________________________ _____________________________________________

SignatureofEmployeeDate DepartmentChairpersonDate

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_____________________________________________ Hoursapproved________________ 

SickLeavePoolAdministrator Date

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Fillable - Sick Leave Pool Form (Little Priest Tribal College)

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