"Medical Certificate for Leave"
APPLICATION TO CANCEL LEAVE STAFF DETAILS Name Staff No Section Campus Internal Phone No Fraction (Full Time or Part Time) PART-TIME STAFF MUST COMPLETE Please specify roster for the fortnight commencing the Friday immediately after pay day. Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Hours LEAVE DETAILS Annual Leave From To Working Days An employee may cancel or vary their annual leave booking, with the approval of their supervisor. This form is used to cancel an existing leave booking. To vary leave dates, another leave application (with new dates) is also required. An employee who is sick during annual leave may request reversal of their annual leave booking. The illness must be for a period of at least 5 consecutive days and a medical certificate must be provided. Sick leave will be booked accordingly. Sick Leave From To Working Days An employee must not return to work prior to the end date indicated on their original medical certificate without first obtaining clearance from a medical practitioner. A new medical certificate is required. Carer’s Leave From To Working Days Long Service Leave From To Calendar Days An employee may cancel or vary their long service leave booking, with the approval of their supervisor. This form is used to cancel an existing leave booking. To vary leave dates, another leave application (with new dates) is also required. An employee who is sick during long service leave may request reversal of their long service leave booking. The illness must be for a period of at least 5 consecutive days and a medical certificate must be provided. Sick leave will be booked accordingly. Leave Without Pay From To Calendar Days An employee will not normally be permitted to reverse their leave without pay booking. Consideration must be given to the arrangements made to replace the employee when the leave was originally approved. Other Leave From To Working Days Specify type of leave For parental, adoption and maternity leave, please contact Human Resources to discuss changes to leave arrangements. SIGNATURE AND AUTHORISATION HUMAN RESOURCES USE ONLY Staff Member: Date: Medical Certificate: Yes No Supervisor: Date: Processed by: Approved: Date: Checked by: V1.2 – 30 September 2009 www.csu.edu.au/division/hr PRIVACY STATEMENT The personal information you provide on this form is protected by the Privacy and Personal Information Protection Act 1998 (NSW) and the Health Records Information Privacy Act 2002. You are required to provide this information to the Division of Human Resources to enable the University to maintain a valid and accurate record of your leave entitlements. Access to the information you provide is available to yourself, your supervisor and Dean/Executive Director and those persons authorised to access the information in the course of their duties to the University. This form will be retained by the Division of Human Resources for a period of six years after which time it will be destroyed. Further details regarding access and notations to personal information provided by you to the Division of Human Resources are set out in the University's policy "Access to Personal Files". D:\Docstoc\Working\pdf\995e57b5-da19-419d-ad38-2fd7c9212160.doc