ࡱ> hjg @ 01bjbjPP 1>:: *******>FFF8~T>e((("""+---=j"'$)R+'i*'**""(*"*"++**" QoyFt5(0e(y,y,>>****y,*$ +''>>d }>>Important: All parties, please complete and route in a timely manner._________________ MEMORANDUM _________________ TO: Director DATE: Human Resource Services FROM: Human Resource Services/Workers' Compensation Office SUBJECT: AUTHORIZATION OF SICK LEAVE AND/OR 100-DAY DIFFERENTIAL Please complete Sections III and IV and return a copy of this authorization form no later than __________________________ to those designated on the circulated copy list. Thank you. SECTION I: TO BE GENERATED / COMPLETED BY HUMAN RESOURCE SERVICES WHENEVER DAYTODAY ABSENCE EXCEEDS BEYOND THREE (3) MONTHS OR FOR CONSECUTIVE 100-DAY GRANT REQUEST Employee Name: ____________________________________________________________________ Social Security Number: _________________________________ o Classified Employeeo Certificated Employeeo Calendar_______o FTE: ________ Payroll: ____________________ Location: _____________________________________________ Number of Days Absent for __________ Fiscal Year as of ______________________ : _____________ Date Days Last Day Worked: _______________________ Physician's Statement(s) on File? o Yes o No (Attach Copies) Number of Accumulated Days/Hours: Sick___________________ Vacation___________________ Tentative End of Vacation: _________________________ Tentative End of 100-Day Differential: _________________________ ___________________________________________________ ________________________ Signature of Human Resource Services Representative(s) Date SECTION II: TO BE COMPLETED BY WORKERS COMPENSATION OFFICE Has Employee Filed Workers' Compensation Claim? o YesClaim Number: _____________________ o No Receiving Benefits at This Time? o Yes o No o Vocational Rehabilitation o Permanent Disability o Temporary Disability o Closed o Denied o Other: ____________________________________________ ___________________________________________________ ________________________ Signature of Workers' Compensation Representative Date SECTION III: TO BE COMPLETED BY HUMAN RESOURCE SERVICES Employee Status: o Day-to-Day Absence o Long-Term Board-Approved Leave of Absence Type: o Health Leave of Absence o Disability Leave of Absence Effective: __________________ Terminating: __________________ o Other ___________________________________________________JKM_j{|~;  8 : t v 2|"$DG  Gbd hL>* hLCJhLCJ OJQJ hL>* hL5hL59CJ(H*aJ(hL59B*aJphhL59B*\]aJphhL59CJ(aJ(hLjhLU?KLM|qf $x$Ifa$ukd8$$Ifl4\T(`@ @ @ (4 laf4 $$Ifa$ $$Ifa$$If01|}~; < $xx$Ifa$$a$ ! 0 0<Okd9$$Ifl40T( !(4 laf4 . v 2|P:{ ! !xdtckd9$$Ifl4&`'04 laf4p   FGHxp ${ !ckd:$$Ifl4&`'04 laf4p $xx$Ifa$ !<  <>ln~$fhjn~(6((())),*.*******P+R+++++,,,,- -$-D-F-J---.b//// 0B00000h_6 h_65U hLCJ hL5hL59B*aJph hLCJhLCJ OJQJhLNH~6(((|<d`wkd:$$Ifl4&`'  04 l` af4p ________________________ Signature of Human Resource Services Representative(s) Date SECTION IV: HUMAN RESOURCE SERVICES USE ONLY o Place Certificated or Classified Employee on 39-Month Reemployment Effective: __________________ Through: __________________ o Payment of Accumulated Sick Leave o Approved o Disapproved Effective: __________________ Through: __________________ o Payment of 100-Day Differential o Approved Differential o End Differential o Activate--Has Exhausted Differential Effective: __________________ Through: __________________ o Physician's Statement o Approved o Disapproved Comments: _______________________________ o Terminate Health Insurance Effective: __________________ ___________________________________________________ ________________________ Signature of Human Resource Services Representative(s) Date cc:Personnel AnalystDistribution by:Workers' Compensation OfficeHuman Resource ServicesPersonnel FileUpon Completion of All Three Sections 12/10/09; Rev. 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