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City of Memphis Sick Leave Bank Distribution Form
Application date
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Division
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City Attorney
City Council
City Courts
Engineering
Executive
Finance
Fire
General Services
Housing & Community Development
Human Resources
Information Services
Library
Office of Planning & Development
Park & Neighborhood
Police
Public Works
Workforce Investment Network
First Name
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Last Name
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Last 4 Digits of Social Security #
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Job Title
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Phone Number
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Have you previously received sick leave from the Sick Leave Bank?
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Yes
No
Did you go by the same name?
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Yes
No
If no, please provide the name and date used during previous distribution request.
First Name
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Last Name
*
Date used during previous distribution request
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+
Your first day absent due to what condition :
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Birth of a Child/Care of Newborn
Serious Health Condition
Servicemember with injury or illness
Child/ Spouse Health Condition
Qualifying exigency arising
First day absent due to condition was
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+
Is your current illness/injury/medical condition work-related?
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Yes
No
Did you file an on-the-job injury claim with the City of Memphis?
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Yes
No
What was the date applied for OJI ?
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+
Have you applied for Social Security disability?
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Yes
No
What was the date applied for Social Security ?
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+
Are you currently approved for or receiving Social Security disability?
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Yes
No
If yes, what was effective date:
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+
Are you currently earning and/or receiving income from other employment? (excluding pensions)
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Yes
No
Name of employer receiving income from
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Have you applied for retirement from the City of Memphis?
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Yes
No
If yes, what was the date applied for Retirement ?
*
+
CERTIFICATION: (Please read and agree)
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I certify that the completed Sick Leave Bank (SLB) Medical Certification form confirms my illness or injury as required by the SLB Guidelines. I understand that the maximum number of hours a member receives for an accident, illness, or an illness related to, resulting from, or recurring from a previously diagnosed illness is 1040 hours or 480 hours if the member is an essential caregiver for an immediate family member, as defined by the Family Medical Leave Act. I am aware that should an investigation show any material misrepresentation of facts, I will not be considered for SLB benefits. The SLB Board may remove me from the SLB, and I may be subject to disciplinary action up to and including termination. I hereby authorize the SLB to make all necessary investigations concerning this application. I further authorize and request any records or information, including but not limited to Medical, Short/Long-Term Disability, Line-of-Duty or Ordinary Disability Retirement, On-the-Job Injury, Family Medical Leave or an accommodation under the Americans with Disabilities Act as Amended that is sought in connection with this application be provided to the SLB.
Please attach Sick Leave Bank Medical Certification Form
*
If applicable
Applicant Verification
First Name:
*
Last Name
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Employee ID #:
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Email Address
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Please Re-Enter Email Address
*