Agency Leave Bank Coordinator:
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Phone #:
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Fax #:
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Last Date Employee Worked:
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Employee needs hours to cover absence from to
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Can agency accommodate a modified duty assignment? Yes No
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Is employee on FMLA leave? Yes No
If yes, provide date FMLA entitlement expires:
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Has employee been on one-day sick slip restriction within the last two years? Yes No
If yes, provide effective date of restriction:
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Has employee been disciplined within the last year? Yes No
If yes, provide effective date of disciplinary action:
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Employee’s last performance evaluation rating was: Satisfactory or Above Less than Satisfactory
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Is this absence due to an on-the-job injury? Yes No
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Has the employee applied for Disability Retirement? Yes No
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Leave Bank Coordinator’s Signature: Date:
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