Name: Date: Dept.: School: Phone number: E-mail address: How many days have you been out for this illness/injury? When did you use up, or when do you anticipate using up your accumulated sick days? Number of sick bank days requesting: Please state existing condition that makes the request necessary: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ As stated in the sick bank language, a catastrophic illness or injury shall be defined as an absence of thirty (30) days or more. Please attach a physician’s statement describing the illness or injury and the number of anticipated days you will need to be out. **Submit this request to Dan Anderson at Fairview School. Upon submission, the Sick Bank Committee will be convened. If more information is required, the committee will contact you. Employee’s Signature __________________________________ |
BLOOMFIELD PUBLIC SCHOOL APPLICATION FOR USE OF SICK BANK |