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Sick Leave Request to Withdraw Form (Procedure 2.2100)
Please complete the following: Last Name:____________________________ First:____________________________ MI.: ____________ Address:__________________________________________________ City:____________________________ State: _____ Zip Code:and__________ Phone Number: ( )____________________________ Social Security No:____________________________ Job Title:____________________________ Department:____________________________ Description of Accident/Illness and/or Injury: _________________________________________________________________ _________________________________________________________________ Current Treatment:____________________________ Hours Requested from Sick Leave Pool:____________________________ Name of Medical Provider:____________________________ Address:____________________________ City:____________________________ State: ________ Zip Code:_________________ Phone Number: ( )____________________________ I HEREBY CERTIFY that the above information is true and correct to the best of my knowledge. I hereby acknowledge that the Advisory Board may request additional information from the above-listed medical provider and agree to provide an Authorization for Release of Medical Records upon request for the above medical condition. I understand that my leave may be terminated upon a determination that the requirements for leave are no longer met. I further understand that any alleged abuse of the Sick Leave Pool shall be investigated and upon a finding of wrongdoing, I will be required to repay all hours drawn and am subject to such other disciplinary action as is determined by the Board of Trustees.
DATE _____________________ EMPLOYEE SIGNATURE____________________________ To be completed by the Human Resource Office I HEREBY CERTIFY that this employee is a member of the Sick Leave Pool of Seminole State College and has an earned sick leave balance of___________ hours as of this date.
DATE ______________________ HUMAN RESOURCE OFFICER______________________ THIS REQUEST IS HEREBY GRANTED FOR ______________________
THIS REQUEST IS HEREBY DENIED ______________________ DATE ______________________ SICK LEAVE POOL ADVISORY ______________________ |
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