EMPLOYEE REQUEST FOR DONATED SICK LEAVE
EMPLOYEE REQUEST FOR DONATED SICK LEAVE
EACC/AFSCME
RECIPIENT’S NAME____________________ EMPLOYEE ID#____________
LOCATION______________________ POSITION______________________
DATE OF REQUEST_________________________
THIS IS ______________________ AN ORIGINAL REQUEST
______________________ A MODIFICATION TO AN EARLIER
REQUEST
EXPECTED DATES OF ABSENCE__________________________________
CONDITION NECESSITATING ABSENCE______________________________
(DOCUMENTATION MUST BE PRESENTED BY PHYSICIAN)
DATE RECEPIENT’S OWN LEAVE WILL BE DEPLETED_________________
DATE ELIGIBLE TO USE DONATED LEAVE___________________________
____________________ REVIEWED BY EACC OR AFSCME (Please circle)
SIGN AND DATE
____________________ APPROVED BY HUMAN RESOURCES CCPS
SIGN AND DATE
Classified Employees fax form to Human Resources at 301-934-7235.
Certificated Employees fax form to EACC at 301-392-0151.
HR/CONFIDENTIAL/SICKLEAVEREQUEST/EMPLOYEEFORM 12/5/07
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