ESTA Sick Leave Bank
Application for Withdrawal From
the ESTA Sick Leave Bank
Applicant’s
Name ______________________________
Date ________________
Home
Street Address _______________________________
City
_________________ Zip
__________ Home Phone
____________________
When
did you become a certificated employee of this district? ___________
Your
approximate number of Sick Leave Days as this school year began ________
Number
of Sick Leave Days you are currently requesting ______________
Work Site
_______________ Work Phone
______________ Email
_____________
A grant of sick leave days from the ESTA Sick Leave Bank
requires that the applicant must have previously contributed one or more sick
leave days to the Bank under the terms established in the Side Letter of
Agreement governing the creation of the Bank.
To qualify for a grant, a participant must exhaust all
personal sick leave and have either: a) A serious illness
or disability; or b) A calamity in their
immediate family requiring their presence.
Typically, the Sick Leave Bank Committee will require some sort of
corroboration of applicants’ claims.
Note: The ESTA Sick Leave Bank Committee cannot alter the
terms of the Collective Bargaining Agreement with respect to bereavement or
personal necessity days. Under the
contract, an ESTA member can utilize a maximum of seven personal necessity days
in any given school year.
In order to review the nature of your needs, the ESTA Sick
Leave Bank Committee will need certain information and authorization from
you. Please fill in the following
spaces:
1. Please provide a statement of the facts
supporting your need for sick leave days (use the back if needed)
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2. What is the total
expected length of your absence, including your own sick leave days?
______________
3. Is a physician’s
verifying report attached? oyes ono Please attach or fax to ESTA at (408) 272-7569
I declare that the above information is complete and
accurate; I
recognize the Sick Leave Bank Committee’s authority to deny or revoke sick
leave days if any statements are found to be untrue; I hereby grant the Committee authority to
review my medical or attendance records at the ESUHSD District Office.
Signed __________________________________ date _______________