Sick Leave Designation

Name (required)

Employee ID (required)

Department (required)

Supervisor (required)

Are you currently on a Workers’ Compensation Leave? (required)

Yes

Are you requesting to use accumulated sick leave to supplement your Workers’ Compensation Leave Benefits as stated in Article 9.2.2 of the WMU/AFSCME Collective Bargaining Agreement? (required)

Yes

How many sick leave hours per pay period are you requesting to use to supplement your Workers’ Compensation Leave Benefits? (required)

Upon exhaustion of your sick leave bank, do you request to use annual leave to supplement your Workers’ Compensation Leave Benefits? (required)

Yes

Sick leave will not be deducted from your sick leave bank until the next full pay period after submission of this designation form.
As stated in the WMU Employee Safety Policy, Policy & Procedures Manual Section 12: “Any employee receiving weekly benefits may use any remaining sick leave in amounts supplementary to weekly workers’ compensation benefit checks, not to exceed 100 percent of regular wages.”
Once sick leave is exhausted, and if annual leave is elected, your annual leave will be utilized until you return from Workers’ Compensation Leave, or your annual leave balance is exhausted.
Your decision is non-revocable and will remain in place until you exhaust your paid leave banks, or return to work.
You continue to remain responsible for any insurance premiums (i.e. health, life, LTD) being charged to you while on Workers’ Compensation Leave. Failure to fully pay an applicable insurance premium may result in loss of continued coverage.
You are responsible for any tax consequences that may result from your decision.

Verification (required)

By clicking this box I verify that I am the employee filling out this form and the information submitted is correct.