Shared Leave Request Form

Employee Information

Name:

Department:

Date Hired:

Home Address Street

City

State KS MO

Zip Code

Home Telephone:

Work Telephone:

E-mail (ex: jdoe@kumc.edu):

Shared Leave Recipient Information

Request is for: Self Family Member
If family member, state name and relationship to employee:

Date Illness/Injury began:

Number of Hours Requested:

Anticipated Duration of time off:

Date all paid leave will be/was exhausted:

Describe and provide any necessary information that would help in concluding that the illness, injury, impairment or physical or mental condition is serious, extreme or life-threatening:


Are you currently receiving Worker's Compensation? Yes No

Have you applied for Worker's Compensation? Yes No

If yes, what date did you apply?

Are you currently receiving Long-term Disability payments? Yes No

Have you applied for Long-term Disability payments? Yes No

If yes, what date did you apply?

Disclaimer

I certify that I understand, agree to, and meet the requirements and conditions of the Shared Leave Program as authorized in K.A.R. 1-9-23. I authorize the Appointing Authority or the Shared Leave Review Committee to obtain any necessary information regarding my request for Shared Leave. I understand that denial of this application is not subject to appeal to the Civil Service Board.
By submitting this application you are certifying that you are the person named on the application. Further that any and all information contained on the application form is complete and accurate. Any material misrepresentation or inaccuracies may result in denial of eligibility or other sanctions.



If you have any questions about completing this form or Shared Leave, contact Lisa Brommer at 316-293-2615.