UPDATED FORM FOR DONATION OF ONE SICK DAY AT VERY END OF ARTICLE
JEFFERSON COUNTY PUBLIC SCHOOLS
SICK LEAVE BANK FOR EMPLOYEES REPRESENTED BY JCAESP/AFSCME LOCAL 4011
PROCEDURES/GUIDELINES
PURPOSE: The purpose of the Jefferson County Public Schools JCAESP/AFSCME LOCAL 4011 Sick Leave Bank is to provide to eligible voluntarily participating employees, who have exhausted all of their accumulated sick, personal and vacation leave, the means of obtaining additional sick leave days upon proper approval of the JCAESP/AFSCME Local 4011 Sick Leave Bank Approval Committee appointed by JCAESP/AFSCME Local 4011.
ELIGIBLE EMPLOYEES: All employees covered by the terms and conditions of the negotiated Agreement between the Board of Education and JCAESP/AFSCME Local 4011 are eligible to voluntarily participate in the Sick Leave Bank. (Union Members and Fair Share Employees)
OPERATING PROCEDURES: The general operating procedures are as follows:
1. Between August 1 and September 1 2012, eligible employees will be afforded the opportunity to enroll
in the JCAESP/AFSCME Local 4011 Sick Leave Bank by voluntarily contributing to the bank
(1) one day from their sick leave accumulation.
2. Non-participating eligible employees will be provided an opportunity to enroll each succeeding August.
3. The JCAESP/AFSCME Local 4011Sick Leave Bank may be opened for re-enrollment of participating
members in any August following a decline to a balance of less than 500 days.
4. Days from the JCAESP/AFSCME Local 4011 Sick Leave Bank may be taken in whole days only except
when they are coordinated with Workers’ Compensation payments.
5. The Jefferson County Public Schools regular sick leave usage policies and procedures as well as a
completed request form will be used as they relate to the JCAESP/AFSCME Local 4011 Sick Leave
Bank when practicable and feasible.
6. Participation is restricted to those eligible employees who have contributed to the Sick Leave Bank and
exhausted all sick, personal and vacation leave.
7. The JCAESP/AFSCME Local 4011 Sick Leave Bank Usage Approval Committee has authority to
request verification of need for the absence certified, by a licensed physician. The Committee may also
request a second independent medical opinion.
8. The Committee retains the authority to prevent abuse of the Sick Leave Bank.
9. No member will be granted more than (20) Twenty days in any given school year.
CRITERIA FOR SICK LEAVE BANK USAGE: The criteria to be used by the JCAESP/AFSCME Local 4011 Sick Leave Bank Usage Approval Committee shall be as follows:
1. Verification of need for the absence certified by a licensed physician.
2. Serious accident and illness of the eligible employee or immediate family* member requiring absences
from work for at least (10) ten consecutive working days.
4. Extended hospitalization of the eligible employee or immediate family* member for at least (10) ten consecutive working days.
5. Other serious extenuating circumstances normally allowed for sick leave as approved the Sick Leave
Bank Usage Approval Committee.
SICK LEAVE BANK USAGE APPROVAL COMMITTEE: The JCAESP/AFSCME Local 4011 Sick Leave Bank Usage Approval Committee shall:
1. Be comprised of (3) three members appointed by the JCAESP/AFSCME Local 4011 President and
approved by the JCAESP/AFSCME Local 4011 Board of Directors.
2. No Committee member shall rule on any usage application of their own or that of a relative.
* Immediate family means the employee’s spouse, children including stepchildren, parents and spouse’s parents, without reference to the location or residence of said relative.
If you would like other information, please contact Deb Force at (502) 368-8052
SICK LEAVE BANK FOR EMPLOYEES REPRESENTED
BY JCAESP/AFSCME LOCAL 4011
DEPOSIT AUTHORIZATION
I, _______________________________, _________________________ assigned to
Name Job Title
_________________________________, Employee ID Number___________________
(Location)
do hereby voluntarily agree to contribute one (1) of my accumulated sick leave days to the
Sick Leave Bank. I understand that this will qualify me to apply for using days from the
Sick Leave Bank according to approved procedures. I understand that my accumulated sick
Leave account will be reduced by one (1) day. I understand that I must apply to the Sick
Leave Bank committee appointed by JCAESP/AFSCME, Local 4011, to use days from the
Sick Leave Bank (and that I still must submit the regular sick leave cards through normal
channels required by the school system.)
Return this form to the JCAESP/AFSCME, Local 4011, 4315 Preston Highway, Suite 101,
Louisville, KY 40213 – no later than Saturday, September 1, 2012 …..only if you wish to
Voluntarily participate in the Sick Leave Bank.
Signature: ____________________________________
Print Name: ___________________________________
Home Address: ________________________________
_____________________________________________
Date: ________________________________________
JCPS SICK LEAVE BANK
APPLICATION FOR DAYS
JCAESP/AFSCME CLASSIFIED STAFF
PLEASE PRINT
Employee Name: _____________________________________________________
Home Address: ___________________________________________Zip:_______
Day time/ Cell Phone: _______________________ Home Phone:___________________
Job Title _____________________________________________________
Name of Payroll Person:____________________________________________________
Location: _____________________________________________________
Employee ID Number:__________________________Hire Date: __________________
Date: ___________________________
Please complete all information, sign and date form
ILLNESS: Explain illness & date illness first occurred
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Attach medical documentation from physician
MEDICAL
DOCUMENTATION: Name of attending physician(s)
_____________________________________ Phone: ________________
_____________________________________ Phone: ________________
Hospital: _____________________________ Date entered: ___________
Date discharged: _____________
ACCIDENT: Was disability/illness caused by an accident? Yes _______
No _______
Date of accident: _________
Was this accident work related? Yes ______
No ______
Describe Accident
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
State medical problems resulting from accident
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Page 1 of 2
WORKERS’
COMPENSATION Is there possible Workers’ Compensation liability?
Yes _________
No __________
DAYS
Number of sick days you are applying for on the application: _______
Last Day Worked ____________________
Date Physician will release you to ____________________
Return to work
Personal Days Left ____________________
Sick Days Left ____________________
Vacation Days Left ____________________
I hereby certify that all of the information provided to the JCPS JCAESP/AFSCME Sick Leave Bank Committee on this application to be true and complete to the best of my knowledge. I have attached medical documentation from my physician.
Employee Signature: ______________________________________
Date: ___________________________________________________
To be completed by JCPS JCAESP/AFSCME Sick Leave Bank Committee
Total Days previously granted _____________________________________
Days granted for this application ___________________________________
Date __________________________________________________________
Committee Signature _____________________________________________
Page 2 of 2
Return completed form to
Sick Leave Bank
JCAESP/AFSCME Local 4011
4315 Preston Highway # 101
Louisville, KY 40213
Phone: 368-8052
Fax: 366-5936
07/16/07 Updated 07/03/12
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