Catastrophic Leave Application Form

Catastrophic Leave Application Form

County of Marin
Human Resources Department
PMR 44 - Leaves of Absence
I hereby request Catastrophic Leave for the following reasons (attach additional sheet if necessary)*
I have read the County Catastrophic Leave Policy and believe I meet all the eligibility requirements. I understand that it may be necessary to provide a physician's statement to verify the injury/illness.
All of my paid leave balances will be exhausted on*

MonthDayYear
All of my paid leave balances will be exhausted on

MonthDayYear
Date
YesNo
SDILTDOther
Department*
Personnel #*
This # is located on the top line of your paycheck to the right of your name
Email*
example@example.com
I agree to the establishment of a time-bank in my behalf. I agree to allow the Human Resources Department to publish a memo to County employees and to solicit voluntary contributions Countywide on my behalf.
Signature*
Signature Date

MonthDayYear
Signature Date

MonthDayYear
Date
Human Resources Use Only
ApprovedDenied
Reason
Director of Human Resources Signature*
Date

MonthDayYear
Date

MonthDayYear
Date
Should be Empty: