Name *

PLEASE NOTE: For anonymity, your name/identity is NOT shared with the Sick Bank Committee.

First Name

Last Name

Classification: *

Licensed Educator (covered by MVEA CBA)

Union Eligible, Non-Licensed Staff (covered by MVEA-ESP CBA)

Accumulated Paid Time Off *

All individual annual and accumulated sick, vacation, and personal leave MUST be used before days will be awarded from the bank.

I have available leave time (excludes Bereavement days).

I have a small amount of leave that will be exhausted prior to a Sick Bank withdrawal (excludes Bereavement days).

I have fully exhausted all of my available Paid Time Off (excludes Bereavement days).

Disability Insurance: *

The Sick Bank may be used to supplement a disability insurance claim, not to exceed an applicant's regular wages. Claim documentation MUST be submitted to the MVSU Human Resources Department.

I do not have Short- or Long-Term Disability Insurance.

I have Short-Term Disability Insurance.

I have Long-Term Disability Insurance.

Expected Dates of Leave - START DATE: *

Enter the first day of leave.

MM

DD

YYYY

Expected Dates of Leave - END DATE: *

Enter the last day of leave.

MM

DD

YYYY