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Extended Sick Leave Request Form

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					Human Resources                                                                                        Benefits Office
                                                                                     555 S Howes Street, Second Floor
Extended Sick Leave Request Form                                                              Campus Delivery 6004
Academic Faculty / Administrative Professionals
Extended Sick Leave Eligibility
When an employee's sick leave usage due to the continuation of a serious health condition
defined under Family Medical Leave (FML) exceeds 30 work days per fiscal year (July 1 – June
30), the cost of the excess sick leave (those days that exceed 30) may be charged to the fringe
benefits pool. FML notice and designation requirements must be met in order to qualify for
eligibility.

Extended Sick Leave Process
The Extended Sick Leave request form is submitted to the Human Resources Benefits Office
along with copies of FML information (Notice of Eligibility and Rights and Responsibilities,
Designation Notice and Medical Certification) by the employee’s department.

Extended Sick Leave Approval
The Human Resources Benefits Office will determine final eligibility under the terms of the
Extended Sick Leave Policy and if deemed eligible, the fringe pool transfer will be initiated.
Should you have any questions regarding this policy, please contact the Human Resources
Benefits Office at (970) 491-6737.
                                        Employee Information
 Name:                                                   Employee ID:

 Department:


                                          Leave Information
 Must be due to the continuation of an employee’s serious health condition defined under FML. All leave
 is denoted as work days.

 1st Sick Leave Day:                                       30th Sick Leave Day:

 Sick Leave used past 30th Work Day (days to be charged to the fringe benefits pool), due to continuation
 of an employee’s serious health condition defined under FML:

         _____/_____/_____   _____/_____/_____   _____/_____/_____   _____/_____/_____     _____/_____/_____


         _____/_____/_____   _____/_____/_____   _____/_____/_____   _____/_____/_____     _____/_____/_____

 (Please use attached calendar if additional space is needed.)
 Sick Leave Balance (as of 31st day of Annual Leave Balance (as of 31st day              Return to Work Date (or
 leave):                                 of leave):                                      anticipated date)”



                                   Department Authorization
 Name/Title:

 Phone #:                                                Date:

 Signature:

 I certify that the employee referenced above has been notified of their FML eligibility and proper
 notification and designation has occurred, is out on Extended Sick Leave and I request that all sick days
 exceeding 30 days (qualifying period) be charged to the Fringe Benefits Pool. I understand that the
 Human Resources Benefits Office will determine final eligibility under the terms of the Extended Sick
 Leave Policy.


                                           www.hrs.colostate.edu                                               11/2011
Human Resources                                                                                                Benefits Office
                                                                                             555 S Howes Street, Second Floor
Extended Sick Leave                                                                                   Campus Delivery 6004
Leave Information

                                ____________________________, _______________
                                          (month)                (year)


    Sunday           Monday            Tuesday         Wednesday           Thursday           Friday           Saturday



 ______ SL Hours   ______ SL Hours ______ SL Hours     ______ SL Hours ______ SL Hours     ______ SL Hours ______ SL Hours

 ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours




 ______ SL Hours   ______ SL Hours ______ SL Hours     ______ SL Hours ______ SL Hours     ______ SL Hours ______ SL Hours

 ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours




 ______ SL Hours   ______ SL Hours ______ SL Hours     ______ SL Hours ______ SL Hours     ______ SL Hours ______ SL Hours

 ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours




 ______ SL Hours   ______ SL Hours ______ SL Hours     ______ SL Hours ______ SL Hours     ______ SL Hours ______ SL Hours

 ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours




 ______ SL Hours   ______ SL Hours ______ SL Hours     ______ SL Hours ______ SL Hours     ______ SL Hours ______ SL Hours

 ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours




 ______ SL Hours   ______ SL Hours ______ SL Hours     ______ SL Hours ______ SL Hours     ______ SL Hours ______ SL Hours

 ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours   ______ AL Hours




  Employee Name____________________________                    Total Annual Leave (AL) Hours Taken____________

  Employee ID________________________________                  Total Sick Leave (SL) Hours Taken______________


  Please record the amount of hours of annual and/or sick leave taken and for which days on
  the calendar. Submit a separate sheet for each month that you are requesting eligibility for
  extended sick leave.


      Page | 1                                 www.hrs.colostate.edu                                                  11/2011

				
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