MDEA Catastrophic Sick Leave Bank Withdrawal Request-Sent To Employee

Mt. Diablo Unified School District

MDEA Catastrophic Sick Leave Bank Withdrawal Request

**HR will use this information to fill out the approval request without your name that will be sent to the MDEA CSLB Committee.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Todays Date*

MonthDayYear
Date
Dates of Absence (Starting)*

MonthDayYear
Date
Dates of Absence (Ending)*

MonthDayYear
Date
Number of Days Requested*
Summary of illness or injury*
Doctor's Note*

Cancelof
Doctor's Name*
19.24.3(a) Catastrophic Leave Bank participants whose sick leave benefits are exhausted may withdraw from the Bank for catastrophic illness or injury. Catastrophic illness or injury shall be defined as any illness or injury that seriously incapacitates the unit member for more than ten (10) consecutive duty days and may include, but not be limited to: Traumatic brain injuries, stroke, effects of HIV, heart ailments, paralysis, etc. Stress shall not be deemed a catastrophic illness under this Article; however, physical manifestations of stress may qualify as catastrophic illness, pending a medical review by a physician of the Committee's choice and at the unit member's expense, per 19.24.3 (g If a reoccurrence or a second illness or injury incapacitates a unit member within twelve (12) months, it shall be deemed catastrophic after five (5) consecutive days.
By signing this form, I acknowledge that the information I am providing is accurate and true. *

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