The Catastrophic Leave Program is available to help support employees who need to take an extended, unpaid leave of absence from work due to an illness or injury that incapacitates either the employee or the employee’s immediate family member.

INSTRUCTIONS:

Read the entire employee statement.

Date and sign form.

Attach medical verification and submit documents to Human Resources

Employee Name: _______________________________________	Date: ______________________

EMPLOYEE STATEMENT (Please initial each)

____ I request to participate in the Catastrophic Leave Program to permit donations of leave credits to my sick balance.

____ I, or a family member, have suffered a catastrophic illness or injury.

____ I have attached a doctor’s verification (containing sufficient information of serious illness/injury including incapacitation and inability to work) to this request.

____ I have exhausted all of my available personal, sick and/or vacation time off.

____ I acknowledge that I cannot receive any other salary replacement income (ex. Disability Insurance, Worker’s Compensation, etc.) while receiving sick time from the Charitable Sick Bank.

Initial Request ☐	Modification ☐	Total number of hours requested: _________

My signature below constitutes my authorization to add the above requested time to my sick time balance.

Employee Signature: ___________________________________________________

--------------------------------------------------- HR Use Only Below This Line ----------------------------------------------

Date Processed: ____________

Approve ☐	Declined ☐	Reason Declined: __________________________________________________

Sick	Vacation	Personal
Current Paid Leave Balances
# Hours Approved
Hourly Rate
Cash Value of Request

Approved By: ______________________________

Signature: _______________________________________