Sick Bank Request Rev. 05/2016 [Type here] [Type here]
GREENVILLE ISD
LESSONS FOR WHEREVER LIFE LEADS
SICK BANK APPLICANT INFORMATION
Employee Name:
Date:
School/Department:
Date of Employment:
Social Security #:
Position/Assignment:
Days absent current school year:
I have donated three (3) days of my sick leave and have been a member of the Sick Leave Bank since:
Reason for Requesting Bank Sick Leave Days
(MM/YYYY)
I have used all of my available state and local sick leave days accrued for this year, and I am requesting sick leave days
because of:
Personal Illness
The illness of a member of my immediate family*
*MUST complete Family Information Form
Number of Sick Leave Days Requested
I am requesting
days from the Sick Bank.
Beginning date:
(MM/DD/YY)
Number of sick leave bank days used during current year to date:
Do you anticipate any additional days to be needed for follow-up examination or treatment?
Yes
No
If yes, please explain: ________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Please describe the illness or injury that the days are being requested for: ______________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
To my knowledge this condition did not exist on the day I joined the Sick Leave Bank. This statement is waived for the
1990 initial enrollment period and for new employees at this first opportunity to join the Bank.
A statement from my physician is attached.
I understand that I will be required to repay the Sick Bank a max of three (3) days in the following school year in order to
continue membership in the bank. If I use less that three (3) days I will donate the number of days actually used.
________________________________________________ _________________________
Employee Signature Date
