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: 
1. Read the entire employee statement. 
2. Date and sign form. 
3. 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: _______________________________________
8003.3a Charitable Sick Bank Request Form                                                                Page  of 1