Form Page: SickLeaveRequest

WAIVER STAFF

First Name

Employee ID

Last Name

Email Address

WAIVER RECIPIENT

SUPERVISOR

Email Address

I am requesting extraordinary use of sick leave because the individual I am regularly scheduled to work with has been:

Hospitalized

Sick at Home

Please provide a detailed description of the circumstances which require you to be off with the individual served.

I wish to be considered for fill-in work with other individuals or departments while I am unable to work my regular schedule.

Yes

I understand that if I do not have enough sick leave accrued to cover my scheduled hours I will need to use vacation time. I understand that in the absence of sufficient accrued sick/vacation hours my leave will be unpaid.

Yes

I understand that if my request is approved I will need to submit a time sheet.

Yes