ࡱ> bda{ bjbjzz .2xJ   8EY| $j(1110$2$2$2$2$2$2$$&(@V$11111V$4k$1d0$10$r4#T#[lvF#$$0$#V )x )# )#01111111V$V$S111$1111 )111111111! : Human Resource Services CSA Catastrophic Leave RequestIn addition to filling out this leave request, you must also attach a physicians statement which must cover the dates listed below. Name: Last 4 Digits of Social Security Number: Street Address: City/State/Zip: Work Phone: Home/Cell Phone: Position Title:School/Department: Date the Catastrophic Leave Will Begin: Date the Catastrophic Leave Will End: Extension to Original Request:( Yes ( NoSignature: Date: If the above request is granted, I agree to the following: I have donated the appropriate amount of sick leave to the Catastrophic Sick Leave Bank for this fiscal year. I have exhausted all paid leaves according to the Catastrophic Sick Leave Bank guidelines. I will comply with the requirements and conditions set forth in the CSA contract. If needed, I will request the allowable additional 20 days in writing and must attach the required doctors note(s) for review and approval. I understand the maximum days available are eighty (80) days per catastrophic illness or injury. I understand that unused Catastrophic Sick Leave Bank days will be returned to the Bank. I have read and understand the Catastrophic Sick Leave Bank guidelines. I will inform Human Resource Services of any changes to my health status.For Human Resource Services Use OnlyDate Catastrophic Leave Request Received:Received By:( Catastrophic Leave Approved( Catastrophic Leave Not ApprovedSignature: Chief Human Resource Services OfficerDatePlease keep a copy for your own records. cc: Human Resource Services, Personnel File Appropriate Supervisor Employee     01/28/13; Rev. 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