Catastrophic Leave Program Request Application

Catastrophic Leave Program Request Application

Instructions for applicants wishing to utilize the Catastrophic Leave Program:

·  Complete the requested information and submit this form to Catastrophic Leave Coordinator located in the City Hall Human Resources Department for p r o c e s s i n g.

·  Only complete submissions including application and all requested accompanying documents will be forwarded to the Catastrophic Leave Committee for review.

·  Please allow 10 business days for processing.

·  This application can be submitted 30 days prior to the date leave is exhausted.

·  The Catastrophic Leave Program has been set up to compensate active full-time employees and active part time employees who have a catastrophic life-threatening medical condition, completed one year's continuous service, and have exhausted all other paid leave. Only active full-time employees who have donated a

onetime minimum of 8 hours and active part-time employees who have donated a onetime minimum of 4 hours

of leave are eligible to apply.

Applicant Information

Employee Name: Employee Number: Department: Length of Service: Contact Number: ( ) - or ( ) - Alternative Authorized Contact Person:

Alternative Authorized Contact Number: ( ) -

Circle One: First Time Request Extension Request

Amount of Leave Requested: Employees may receive leave distributions from the fund for up to three months (90 days). Extensions beyond the ninety- first day would require approval by the Catastrophic Leave Program Committee. Extensions can be granted in monthly increments with a lifetime maximum of six months total leave awarded. Extension approvals must be supported by the appropriate medical information provided by the recipient of the leave.

Attach doctor’s diagnosis and prognosis of medical condition to this application

Attach the completed Catastrophic Leave Physician’s Certification Form to this application

I hereby submit this application and attest that all statements and attached documents are accurate. I also authorize the Catastrophic Leave Coordinator and Committee to review any records which may pertain to this application, including medical records and other records deemed confidential under the law.

Employee Signature Date

Catastrophic Leave Coordinator Use Only

Date Received:

Received By:

Date Processed: Committee Review Date:

Circle One: Application Approved Application Denied

PER-FRM-568 Rev 1 1/1/2016