Human Resources
University - 8000 York Rd, Towson MD 21252 - 410-704-2162 - towson.edu/hr
September 2019
Request for Advanced
Employee Name, ID, and FTE:_______________________________________________________________
Department:____________________ Title:______________________ Date of Hire:____________________
Contact Information (Email/Phone):___________________________________________________________
Onset of illness/disability:_______________________ Date current leave exhausts:_____________________
Projected return date:_________________________ Number of ASL days requested:___________________
Employee Acknowledgement
I understand and acknowledge the following information:
This request is subject to the terms and conditions in USM Policy VII-7.45 – Policy on Sick and Safe Leave for
Non-Exempt and Exempt Staff Employees (the Policy), which I have read and understand.
ASL may be available to an eligible employee that sustains a temporary, recoverable mental or physical
illness, injury, condition, or serious disability, and who has exhausted all other forms of available leave.
An employee requesting ASL must have a satisfactory record of work performance and no record of sick
leave abuse.
ASL is not an entitlement and my request is subject to review and approval by the Office of Human
Resources (OHR) upon receipt of this signed form, supporting medical documentation from my treating
health care provider, operational needs, and other terms and conditions of the Policy.
The use of ASL constitutes a debt for which payment shall be enforceable upon the employee’s return to
work or upon the employee’s separation from employment, whichever is earlier.
Upon return to work, the minimum rate of ASL repayment shall be at one-half the rate that sick leave and
annual leave is earned.
ASL may also be repaid by applying any earned leave to the balance or by reimbursing the university with
cash.
Additional requests for ASL will not be granted until all previously granted ASL has been repaid. The only
exception to this provision is when the maximum amount of ASL was not originally requested and additional
ASL, consecutive to that already granted, is needed to cover a continued absence arising from the original
illness, injury, condition, or disability.
ASL may only be used for absences related to the illness, injury, condition, or disability for which leave was
requested.
Print Name:____________________________________________________________________________
Signature __________________________________________________________Date: _______________
click to sign
signature
click to edit
![]()
