tangipahoa parish school system sick leave bank request for days form

TANGIPAHOA PARISH SCHOOL SYSTEMSICK LEAVE BANK REQUEST FOR DAYS FORMPERSONAL INFORMATION__________________________________________________SOCIAL SECURITY NUMBER__________________________________________________LAST NAME__________________________________________________FIRST NAME__________________________________________________STREET/POST OFFICE BOX__________________________________________________CITY, STATE, ZIP CODEPOSITION(Check one.)( ) TEACHER*( ) BUS DRIVER( ) OTHER*(includes all positions where the employee musthold a valid Louisiana Teacher’s Certificate)NUMBER OF DAYS REQUESTED FROM THE SICK LEAVE BANK: __________Please give a description of the illness or accident related to the request for Sick Leave Bank Benefits. (Additional sheetsmay be used if necessary.)__________________________________________________________________________________________________________________________________________________________________I hereby authorize the Tangipahoa Parish School System to release information from my personnel file regarding my medical history,doctor’s records and/or letter, and use of sick leave in order that the Sick Leave Bank Committee may determine if I am eligible forleave days from the Sick Leave Bank. I understand the Sick Leave Bank Policy and that the decision of the Sick Leave Committee isfinal. I also affirm that at the time I joined the Sick Leave Bank, I was unaware of the condition for which I am requesting days.________________________________________Employee’s Signature (or family member/agent)_______________________________Date SignedFOR SICK LEAVE BANK COMMITTEE OFFICE USE ONLYREQUEST APPROVED: ( ) YES ( ) NONUMBER OF DAYS APPROVED: _________COMMENTS: ____________________________________________________________________________SIGNATURE OF COMMITTEE CHAIR: ____________________________________ DATE: _____________Revised September 2012FILE: GBRIBB

members of the Committee for action. The Committee shall consider both physicians’ reports before rendering adecision.Sick Leave Bank CommitteeThe Human Resources Director, the Director of Business Services, the Director of Pupil Services, the Director of Curriculumand Instruction, Director of Transportation, the Director of Child Nutrition, and Head School Nurse shall serve on the Sick LeaveBank Committee. The chair of the Committee shall be the Human Resources Director. The Committee shall review anddetermine approval or denial for utilization of Sick Leave Bank days in accordance with the provisions of this policy.A majority vote of the members of the Sick Leave Bank Committee shall be necessary to approve a member’s request. Adecision on a member’s request may be made by a quorum of the Committee in the event that one or more members are notavailable to participate in the review. The Committee shall notify the employee of its decision to approve or to deny therequest within fifteen (15) days of the receipt of the request. The decision of the Sick Leave Bank Committee to approve orto deny requests shall be forwarded to the Superintendent for review and approval. The Superintendent’s decision shallbe final and binding, and such decisions shall not be subject to review by the School Board or subject to the Board’sgrievance procedures.Forms and Record Keeping1. The Human Resource Department shall maintain all records regarding operation of the Bank.2. All Sick Leave Bank Membership Enrollment Forms, Sick Leave Bank Request for Days Forms, and Physician’sStatement Forms shall be kept up-to-date by the Human Resources Department and shall be available on theTangipahoa Parish School Board’s website.3. Copies of all completed forms shall be kept on file by the Human Resources Department. Sick Leave BankMembership Enrollment Form(s) shall be checked for full-time employee status and who have been employed for atleast one-year within the district.Exclusions and LimitationsThe Tangipahoa Parish School Board reserves the right to amend the Sick Leave Bank program at any time. Days donated tothe Sick Leave Bank by each employee shall be converted to a “value” based on the donating employee’s daily rate of pay atthe time of the donation. Withdrawn Sick Leave Bank days shall also be based on the employee’s daily rate of pay until suchtime as there is no money left in the Sick Leave Bank for that year. Sick Leave Bank Days (or value) withdrawn shall be grantedwithin the school year or fiscal year. Sick Leave Bank Days shall not be carried over from one school year to another or fromone fiscal year to another. Sick Leave Bank days (or value) not used in any one fiscal year shall be forfeited at the end of thefiscal year. The Sick Leave Bank shall start anew each successive fiscal year. In no case shall the withdrawal of Sick Leave BankDays (or value) cause a member to receive more salary than his/her annual salary.New policy: August, 2012 Ref: La. Rev. Stat. Ann. ''17:81, 17:500.2, 17:1202, 17:1205, 17:1206.2; La. Civil Code, Art. 1541, 1542, 1833.