Employee Sick Time Request Form

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Employee Sick Time Request Form Powered By Docstoc
					Emergency Sick Time Bank
The Emergency Sick Time Bank was created collaboratively to benefit
             the employees of Paul Smith’s College.




                                     Staff
                                    Advisory
                                    Council




                         Human
                        Resources


                                        Emergency
                                         Sick Time
                                           Bank
                   What is it?
→Modeled after plans at other colleges

→A “bank of sick time” that will maintain a balance of
 not less than 20 donated days

→Donated by staff for use by other staff employees
   – Who are unable to work because of a serious medical
     condition themselves
   – Who have an immediate family member who has a serious
     medical condition as defined by the Family Medical Leave
     Act (FMLA)
    How can I donate days?
 Voluntary, but you must donate to the bank in order to
  borrow from the bank.
 Donate after one year of service
 Retain at least 5 days of your own individual sick leave
  accrual
 Donate up to half of your accrued sick leave, i.e., an
  employee who has 40 days accrued may initially donate
  up to 20 days to the Emergency Sick Time Bank
 Once time is donated, it may not be reclaimed
 You alone are responsible to retain adequate sick time for
  yourself.
  When Can I Donate Days?
• Initial Donation Period (Sept. 2009)
• Scheduled Times Each Year
        Anniversary      Donation Period

         1/1 – 3/31      First week of April

         4/1 – 6/30      First week of July

         7/1 – 9/30     First week of October

        10/1 – 12/31    First week of January
  How May I Request Days?
You must meet the following initial criteria:
 Qualify for leave under the Family Medical
  Leave Act, and
 Use all accrued sick and vacation leave, and
 Apply for Short Term Disability Insurance
  (STDI), if eligible. (Employees may apply
  STDI proceeds to buy back sick time for
  repaying the Sick Bank), and
 Provide a physician’s certification.
       How Are Awards Made?
 Meet initial criteria
 Complete Emergency Sick Bank Request Form,
 Staff Matters Sub-Committee meets to consider
  request, based on:
   • Balance of days in the Emergency Sick Time Bank
   • Bank must maintain a minimum balance of 20 days
   • Number of concurrent requests for awards
   • How much, if any, prior awards you may have
     received
   • Awards will be considered on an as-needed basis.
     What Amounts Can Be
          Awarded?

 No more than 10 days per year
 No less than 1 day at a time (=no partial days)
 If additional time is needed and requested,
  it may be granted at the discretion of the
  Board. Additional documentation may be
  required.
How Does Repayment Work?
 If you borrow, you must pay back
 Equal number of days
 Schedule determined when leave is granted
 If extended leave, payback period may be
  adjusted to require that no more than 50% of
  an employee’s annual sick accrual is paid
  back in one year.
Q. What If An Employee Fails to Repay
  Time?
A. Not eligible to request time from the Bank
  again.

Q. When I Retire or Resign May I Donate
  My Leftover Time?
A. No.
Who Manages the Sick Bank?
 Who Approves Requests?
   You the Employee
   • Completes forms
   • Submits forms to HR Benefits
     Manager

       HR Benefits Manager
       • Convenes Board
       • Advises Board of Sick Bank status
       • Maintains confidential information
         (HIPAA)

            Sick Bank Board (Staff Matters
            Subcommittee)
            • Reviews request
            • Makes determination
Sick Bank Criteria Form
                                                                                  Sick Bank Criteria Form

  Employee to Complete

  Employee Name _______________________________________________ Anniversary Date__________________

  Department ___________________________________________________

  Staff employees may request an award of days once they meet the following initial criteria:

          1.   Do you qualify for and have filed for leave under the Family Medical Leave Act?
                    Ye
                No  s Please give a brief description why you are in need of additional leave.



          2.   Have you used all accrued sick and vacation leave?                             No     Ye
                                                                                                       s

          3.   Have applied for Short Term Disability Insurance (STDI), if eligible?          No     Ye
                                                                                                       s

          4.   Have you provided a physician’s certification?                                 No     Ye
                                                                                                       s

  Please refer to Downloadable Forms on the HR Web Page for all required forms that must be
  submitted in addition to the S Bank Criteria Form. (i.e., Request for Family or Medical Leave, Medical
                                ick
  Certification: Family Member - Employee, Disability Statement of Rights, DB-450 Claim Form).


  Employee Signature                                                                   Date _____/ _____/ _____


  ________________________________________________________________________________________________

  To be completed by Human Resources

  Criteria Met         (   )                Criteria Not Met      (   )

  Human Resources Signature                                                            Date _____/ _____/ _____

  Title


  Notes:

  ______________________________________________________________________________________

  ______________________________________________________________________________________

  ______________________________________________________________________________________


  Routing:             Affirmation completed by Human Resources                               6/ 09
                       Original Personnel File
                       Copy to E mployee
Sick Bank Request Form
                                                                                        Sick Bank Request Form

  Employee to Complete

  Employee Name _______________________________________________ Anniversary Date__________________

  Department ___________________________________________________

  Has your personal leave time been exhausted or will it be in the near future?
  No  If yes, when?
        Yes

  Have you previously requested sick bank time?
  No  If yes, when and for how many days?
        Yes
            If yes, was previously awarded time repaid to the Sick Bank? No            
                                                                                        Yes


  Proposed repayment time period to sick bank                                                 /
                                                                          Target Date                             Frequency



  How many days are you requesting from the Sick Bank?
  Employee Signature                                                                              Date _____/ _____/ _____

  ________________________________________________________________________________________________

  To be completed by Human Resources

  (   ) The Sick Bank Criteria has been met                     (   ) The Sick Bank Criteria has not been met

  Human Resources Signature                                                                       Date _____/ _____/ _____

  Title

  ________________________________________________________________________________________________

  To be completed by Staff Matters Committee

  (   ) Approved                               (   ) Not Approved


  Staff Matters Co-Chair Signature _______________________________________________Date _____/ _____/ _____

  Staff Matters Co-Chair Signature _______________________________________________Date _____/ _____/ _____

  Notes:

  ______________________________________________________________________________________

  ______________________________________________________________________________________

  ______________________________________________________________________________________

  Routing:                                                                                                        6/ 09
                     Original Personnel File
                     Copy to E mployee
                     Copy to Staff Matters
                     Copy to Sick Bank/ HR
Sick Time Donation Form
                                                                                          Sick Time Donation Form

    Employee to Complete

    Employee Name _______________________________________________ Anniversary Date__________________

    Department ___________________________________________                     xempt E
                                                                                E      mployee 
                                                                                               Non-Exempt Employee


                                  Current Balance                              Sick Days to Donate

    Initial Donation Period      _______________                              ________________
        (September 1 - 30)
    Open Donation                _______________                              ________________

                        Anniversary                         Open Donation Period

                        1/ 1 – 3/ 31                        First   week of   April
                        4/ 1 – 6/ 30                        First   week of   July
                        7/ 1 – 9/ 30                        First   week of   October
                        10/ 1 – 12/ 31                      First   week of   January

    Employee Signature __________________________________________________                       Date _____/ _____/ _____


    ________________________________________________________________________________________________

    To be completed by Human Resources

    (   ) Donation Approved                             (   ) Donation Not Approved

    Human Resources Signature ________________________________________________Date _____/ _____/ _____

    Title ______________________________________________________________________________________



    Notes:

    ______________________________________________________________________________________

    ______________________________________________________________________________________

    ______________________________________________________________________________________

    ______________________________________________________________________________________

    ______________________________________________________________________________________


    Routing:            Affirmation completed by Human Resources                                        6/ 09
                        Original Personnel File
                        Copy to E mployee
                        Copy to S ick Bank
    Where Are These Forms?
On the HR webpage
      http://www.paulsmiths.edu/offices/hr/forms.php
            Questions?
Contact the Staff Advisory Committee
       Or Human Resources

				
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