Leave Sharingapplication Form

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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