Colorado School of Mines

Leave Sharing Bank Program
Application for Use of Bank Leave

PART I: To be completed by employee (please type or print legibly in ink).

Name:___________________________________________ CWID #:_______________

Home Address City/State/Zip: _____________________________________________________

Home Phone: ________________________________
Work Phone:______________________

Department/Agency: Higher Education/Colorado School of Mines





CSM Department: _______________________________________________________________

Title:______________________
Date Service Began:_____________________________

Request is for:
Self
Child
Parent
Spouse
Other

Are you requesting/applying for: (if applicable)

Short-term Disability
Worker’s Comp
Disability Retirement

Number of hours requested:_______________________________________________________

Briefly describe the nature of illness/injury or catastrophic
event:_________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

I hereby certify that I understand, agree to, and meet the requirements and conditions of the Leave
Sharing Bank Program. Also, I hereby authorize the CSM President or his designee to obtain any
necessary information concerning this application. I understand that denial of this application is
not subject to grievance or appeal.

Signature of Employee:____________________________ Date:_____________________

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PART II: To be completed by Supervisor.

I hereby certify that, to the best of my knowledge, the above information is accurate. Also, I
hereby certify that if the application is approved, authorization to use that leave is granted.

Signature of Supervisor:___________________________ Date:_____________________

TO BE COMPLETED ONLY FOR MEDICALLY RELATED REQUESTS
PART III: Attending Physician’s Statement (please type or print legibly).

NAME: _________________________________________
Phone #: __________________

Address City/State/Zip: __________________________________________________________

Date first consulted for this condition:_______________________________________________

Briefly describe the nature, diagnosis, and treatment of illness/injury:______________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Anticipated duration employee is unable to work due to condition or direct care of family
member
From:___________________________
Through:_______________________________

Signature of Physician:______________________ Date:____________________________

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PART IV: To be completed by Colorado School of Mines Human Resources Department.

The above named employee has/will have exhausted all annual and sick leave as of
______________________________.

Authorized Signature:______________________________
Date:_____________________

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FOR CSM PRESIDENT USE:

Application was received on: ________________________________________

DECISION: (check one)
Approve

Reject

Authorized Signature:___________________________________________ Date:____________












Revised 9/01/02