Sick and Safe Leave -Employee Request Form-Substitutes and Temps Only

Sick and Safe Leave -Employee Request Form-Substitutes and Temps Only

Sick and Safe Leave is ONLY for Substitutes and Temps

Employee-last name*

Employee-first name*

Employee-EIN*

Employee-City Schools email*

Supervisor's name*

(person authorized to approve leave)

Supervisor's City Schools email*

Date requested time is to begin*

Date to return to work*

Hours requested*

Is your normal work schedule greater than 4 hours per day?

Yes

Hours requested-1

If your normal work schedule is 4 hours or less per day then you must select in full day increments.

(1 full day)

(2 days)

Hours requested-2

If your normal work schedule is greater than 4 hours per day then you may select in half day increments.

(half day)

(full day)

(1 1/2 days)

(2 days)

Do you have enough SSL hours for this request?*

Please login to your ESS account and review your SSL balance (recognizing that hours shown are current as of the last date of pay).

Yes

What is your current SSL balance?*

File Upload-Documentation

Please upload proof of medical appointments, physician orders, legal appointments/court appearances, etc.

This is for both FORSEEABLE and UNFORSEEABLE occurrences.

FORSEEABLE-(If the need to use sick and safe leave is foreseeable (for example, a scheduled doctor’s appointment), the employee must provide notice 7 days prior to leave use by complying with and completing the procedural requirements for requesting or reporting use of earned sick and safe leave.) If the leave is for more than two consecutive shifts (i.e., three or more workdays in a row), your supervisor may request that you provide verification that the leave use was appropriate by uploading acceptable documentation.

UNFORSEEABLE-Please also provide a brief explanation, in the space below, as to why this leave was not foreseeable.

Please only include official documentation with names, dates and times.

DO NOT provide personal health information (City Schools will not be responsible for protection of personal health information).

Drag and drop files here or

Comments or additional information

Please write any information you may deem necessary in processing this request.

Acknowledgement of Truth

Attest to Truthfulness*

I declare and affirm the accuracy of the information contained herein. I understand that submitting false information is misconduct that may lead to disciplinary action up to and including termination of employment.

YOU MUST SELECT TO RECEIVE A COPY OF THIS FORM

You must select in the box below to receive an electronic copy of this form.

Submission of this form is not confirmation of processing or approval. It is only the first step of completing the electronic application. Your supervisor must review and approve or deny electronically.

Send me a copy of my responses

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