LEAVE SHARINGAPPLICATION FORM
In accordance with UCCS Policy 300-007
PART 1—TO BE COMPLETED BY THE EMPLOYEE
NameEmployee ID #
Title Department
Request is for: SelfChild ParentSpouse
This injury/illness qualifies for (Please review with Human Resources and Check all that apply):
Short-Term Disability Worker’s Compensation Disability Retirement None
Date illness/injury began Anticipated duration______
Date when all paid leave, including compensatory time, will be/was exhausted ______
Number of days of leave requested ______
Briefly describe the nature of illness/injury/event: ______
____
____
____
____
I hereby certify that I understand, agree to, and meet the requirements and conditions of the Leave Sharing Program. I acknowledge that I have completed one year of service and am eligible for FML. Also, I hereby authorize the Chancellor, or designee, to obtain any necessary information concerning this application, understand that the Chancellor reserves the right to approve a waiver and that denial of this application is not subject to grievance or appeal.
Signature of EmployeeDate
PART 2—TO BE COMPLETED BY THE HIGHEST RANKING SUPERVISOR: DIRECTOR, EXECUTIVE DIRECTOR or ASSISTANT/ASSOCIATE VICE CHANCELLOR
I hereby certify that, to the best of my knowledge, the preceding information provided by the employee is accurate. I hereby certify that if the application is granted, authorization to use the leave is granted. I acknowledge that approval of this request commits this department to pay the salary and benefits associated with this leave.
Signature of Director, Exec Director or AVCDate
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PART 3—ATTENDING HEALTH CARE PROVIDER’S STATEMENT –(for catastrophic medical hardship requests)
Medical Provider’s Name______Phone ______
Address/City/ZIP____
Date first consulted for this condition ____
Briefly describe the nature, diagnosis, and treatment of illness/injury: ______
____
____
Please provide the anticipated duration of time that employee will be unable to work due to their condition or the direct care of their family member:
from: __through: ______
Signature of PhysicianDate
PART 4—TO BE COMPLETED BY THE UCCS OFFICE OF HUMAN RESOURCES
The employee began permanent service on , works %time, and
will exhaust all accrued leave, including any short term disability, as of____.
The employee has completed one year of service amd is eligible for coverage under the FMLA.
The employee has not completed one year of service and does not qualify for FML.
Agrees that this request meets the defined criteria for shared leave
This requestdoes notmeet the defined criteria for shared leave (see supporting docments)
Yes, the Leave Bank can support this request
No, the Leave Bank cannot support this request and will need to solicit contributions
__
Signature of Director of Human ResourcesDate
PART 5—TO BE COMPLETED BY THE EMPLOYEE’S VICE CHANCELLOR or CHANCELLOR
I approve this request. ______days of transferred leave shall be awarded from the Leave Bank to this employee.
I reject this request.
Signature of Vice Chancellor or ChancellorDate
PART 6—WAIVER TO BE COMPLETED BY UCCS CHANCELLOR
I approve the the waiver of this request. ______days of transferred leave shall be awarded from the Leave Bank to this employee.
I reject this request for waiver.
Signature of ChancellorDate
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