DEC(EXHIBIT) - COMPENSATION AND BENEFITS: LEAVES AND ABSENCES
See the following pages for procedures describing request and approval of Catastrophic Sick Leave.
How to request catastrophic leave after an employee has exhausted all state and local leave.
The employee must request a catastrophic leave packet from the campus principal, learn the definition of catastrophic leave and the criteria for qualifying for such leave.
If the employee qualifies, he or she must fill out the request for catastrophic leave form and return the form to the campus principal.
If the campus principal confirms that the eligibility criteria have been met, the employee must fill in the employee information on the attending physician's statement and have the attending physician complete the rest of the form.
Submit the catastrophic leave request form and the attending physician's statement form to the Superintendent's office.
If the request is approved, the Superintendent will notify the campus principal, the employee requesting the catastrophic leave and the payroll department.
The campus principal will notify his or her staff of the creation of catastrophic leave pool for the employee.
Required Forms, below
Catastrophic Leave Request Form
Attending Physician's Statement Form
CATASTROPHIC LEAVE POOLREQUEST FOR CATASTROPHIC LEAVE
Please complete this form and return to the Superintendent's office. An official attending physician's statement must also be on file for this request to be considered. Ordinarily, a decision should be made and communicated within ten working days.
Catastrophic illness plan benefits must be used only for catastrophic illness or disability of the employee or the serious health condition of the employee's parent, spouse, or child.
SS Number: ___________________ Position:
Patient's name if different than above:
Relationship to employee:
I have or will have used all of my available state and local leave, as well as any compensatory time and vacation days, as applicable.
I am requesting leave: Begin ______ / ______ / ______ End ______ / ______ / ______modayyrmodayyr
Nature of Illness or Injury:
Date illness began or accident occurred: ________________
Date physician was consulted: ________________
Name, address, and phone number of attending physician:
Did the condition require hospitalization? Yes ________ No_______ If yes:
Name of Hospital:
Date of Confinement:
Is this condition eligible for Workers' Compensation?
Will you be eligible to draw upon your disability insurance?
If yes, give the date:
I certify that the information given on this Request for Catastrophic Leave is valid.
CATASTROPHIC LEAVE POOL
ATTENDING PHYSICIAN'S STATEMENT
Complete the employee information and authorization portions below. The attending physician will complete the remainder of the form and return to Administrative Services. Request for CLP days will not be considered until the Attending Physician's Statement is received.
Employee's Name: _________________________ SS Number:
Campus/Department: __________________________________ Date:
Patient's Name__________________________ Relationship to employee:
Please complete the following information regarding the patient named above. Describe illness or injury in detailed, lay terms:
Attending Physician Name:
Explain the short-term and long-term prognosis:
Dates of treatment:__________________ Is patient still under your care?
Name and address of hospital:
Date admitted: ______ Date discharged: ______ Is this condition due to pregnancy? ______
Answer only if the patient is a District employee:
As you understand this patient's job responsibilities, from your professional assessment of the patient's current condition, can you recommend this person to return to work at this time to perform his or her regular job assignment?
If the answer is no, what is the anticipated date of return to work?
Return completed Attending Physician's Statement to:
Bartlett ISDP.O. 170Bartlett, TX 76511