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NISKAYUNA TEACHERS ASSOCIATION
Sick Bank Utilization Request
Form
Employee
Full Name __________________________________
Building
____________________________________________
Date
_______________________________________________
1.
Please describe the nature of the
illness/disability (if due to an accident,
provide date, time, place and circumstances of
accident). Please attach physician
note/orders.
2. First day of proposed sick bank usage
_______________________
3. Name of physician
______________________________________
4. Physician telephone number
_______________________________
** Sick leave bank use stops upon
the first day of eligibility under the
district's long-term disability insurance plan
or upon the first day of availability for work
according to a signed, dated doctor's note.
I
certify that the above information is correct,
to the best of my knowledge.
Employee signature
___________________________________ Date
____________
--Office Use Only--
Total # of available sick
days: _______
Dates of eight work day unpaid waiting period:
__________________
Date of contact with physician:
_________________
Date of correspondence to employee regarding
status: _____________
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