Name

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

First Name

Last Name

For anonymity, this is NOT shared with the Sick Bank Committee.

Classification:

Administration (Licensed or Non-Licensed)

Licensed Educator (covered by MVEA CBA)

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

Non-Union Eligible, Non-Licensed Staff

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.

I have a small amount of leave that will be exhausted prior to a Sick Bank withdrawal.

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

Expected Dates of Leave - START DATE:

Enter the first day of leave.

YYYY

Expected Dates of Leave - END DATE:

Enter the last day of leave.

YYYY

Number of Days Reqested:

Enter the total number of days you are requesting to withdraw from the Sick Bank.

Please state the reason for your Sick Bank withdrawal request:

PLEASE NOTE: THIS WILL BE SHARED with the Sick Bank Committee and is used to evaluate the request in accordance with the qualifications for and procedures of the Sick Bank.

Notes:

Additional information you feel is relevent to this request.