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State employees' leave bank request form section 1 – To Be Completed by Employee

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SECTION 1 – To Be Completed by Employee



Social Security Number (9 digits):      

NOTE: Providing your full Social Security Number will help us verify your identity. Failure to provide it may result in rejection of your request. Your number will be kept confidential in accordance with Federal and State laws and regulations.

Home Address:







SECTION 2 – To Be Completed by Agency Leave Bank Coordinator

Agency Leave Bank Coordinator:      

Phone #:      

Fax #:      

Last Date Employee Worked:      

Employee needs      hours to cover absence from      to      

Can agency accommodate a modified duty assignment? Yes  No 

Is employee on FMLA leave? Yes  No 

If yes, provide date FMLA entitlement expires:      

Has employee been on one-day sick slip restriction within the last two years? Yes  No 

If yes, provide effective date of restriction:      

Has employee been disciplined within the last year? Yes  No 

If yes, provide effective date of disciplinary action:      

Employee’s last performance evaluation rating was:  Satisfactory or Above  Less than Satisfactory

Is this absence due to an on-the-job injury? Yes  No 

Has the employee applied for Disability Retirement? Yes  No 

Leave Bank Coordinator’s Signature: Date:

SECTION 3 – To Be Completed by Appointing Authority or Designee:
This employee has exhausted all forms of annual, sick, personal and compensatory time because of a serious and prolonged medical condition. The employee has been a member of the Leave Bank for at least 90 days or has been granted an exemption by the Secretary of Budget and Management. Approval will not cause the employee to exceed 2,080 hours of leave from the Leave Bank and Employee-to-Employee Leave Donation Programs during his/her entire State employment. Approval will not cause the employee to exceed 16 months of continuous leave, when combined with all other forms of paid leave. As the appointing authority for this employee, I have reviewed the employee’s records and I certify that this request meets all of the criteria specified in Section 3.
______________________________________________________________ ______________________________________

Signature of Appointing Authority or Designee Date
MS 408

(Revised October 2015)

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