FLORIDA DEPARTMENT OF CORRECTIONS

APPLICATION FOR SICK LEAVE POOL MEMBERSHIP

Part 1 – Requesting Member’s Information
Applicant completes ‘Part 1’ and forwardsto:
Sick Leave Pool Administrator
Department of Corrections, Central Office, Bureau of Personnel
501 South Calhoun Street
Tallahassee, FL 32399-2500
Phone: 850-717-3204 Fax:850-922-9352
Name:
People First #:
Work Email:
Telephone # where you can be reached:
/ Position Title:
Region:
Location/Institution:
Supervisor Name:
Supervisor Phone #:

I,,hereby elect to join the Department’s Sick Leave Pool.

I certify that I havebeen employed by the State of Florida in a Career Service (CS), Selected Exempt Service (SES), or Senior Management Service (SMS) position for at least one (1) full year.

I certify that I currently have at least sixty-four (64) accrued hours of sick leave.

I certify that I am a full-time or part-time CS, SES or SMS employee with the Department of Corrections.

I authorize my PersonnelOffice tocontribute eight (8) hours of my sick leave to the pool upon approval of this application and an additional eight (8) hours each time the pool reaches the predetermined depletion level of 2400 hours not to exceed 24 hours in a calendar year.

I hereby certify that all information above is true, and I understandthe requirements of the Department of Corrections Sick Leave Pool, asprovided in “Sick Leave Pool,” Procedure 208.059.

______/_____/______

Employee Signature Date Phone

Part 2 – Leave Certification
HR completes ‘Part 2’ and forwards to the Sick Leave Pool Administrator

Date request was received: //

I certify that the above named employee is eligible ineligibleto join the SickLeave Pool. Accrued sick leave balance

as of// is hours. Date of hire is//.

______/_____/______

Bureau of Personnel Date Phone

Part 3 – Sick Leave Pool Administrator’s Review and Approval
The Sick Leave Pool Administrator forwards the approval/disapproval to the employee’s
Servicing Personnel Office

The above named employee is APPROVED to join the SickLeave Pool. Please deduct 8 hours sick leave from the employee’s accrued balance, place the original form in the employee’s official personnel file and forward a copy to the employee. The comment ‘Sick Leave Pool Hours Donated’ must be included in the comment section of the corresponding PF timesheet and Leave Balance Adjustment Detail Comment section.

The above named employee is DISAPPROVED to join the Sick Leave Pool. Please place the original form in the employee’s official personnel file and forward a copy to the employee.

______/_____/______

Signature - Sick Leave Pool Administrator Date Phone

DC2-8038 (Revised 6/11/13)