Yosemite Community College District
Human Resources Operations
Rev. 01/22/2013
Request for Extended Sick Leave
Employee Application Form
Upon exhaustion of an employee’s full salary sick leave, additional half-salary sick leave is available in an
amount of up to 100 days per year for regular full-time employees and a pro-rata amount for part-time employees.
This half-salary sick leave is known as “extended sick leave” (ESL).
To be completed by the employee:
Name: ___________________________________________ Colleague ID: _____________________________
Division/Dept.: ______________________ Campus: MJC Columbia Central Services
I, ____________________________________, acknowledge all of my accrued sick leave has been
exhausted. I am requesting Extended Sick Leave (ESL). I understand I must provide a medical certification
with an extended sick leave absence. I also understand ESL is paid at 50% of my regular salary.
ESL may be supplemented with available Vacation and/or Comp Time. I request to supplement any ESL as
stated below:
50% Paydock
Available Vacation and/or Compensatory Time Off (CTO)
____________________________________________________________ __________________________
Signature of Employee Date
APPROVED BY:
____________________________________________________________ __________________________
Immediate Supervisor Date
To be completed by the YCCD HR Ops/Benefits Office:
1
st
Date of ESL: __________
_____________________________ ____________________________________
Date Signature
Comments:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
