ࡱ> hjg @ 01bjbjPP 1>:: *******>FFF8~T>e((("""+---=j"'$)R+'i*'**""(*"*"++**" QoyFt5(0e(y,y,>>****y,*$ +''>>d }>>Important: All parties, please complete and route in a timely manner._________________ MEMORANDUM _________________ TO: Director DATE: Human Resource Services FROM: Human Resource Services/Workers' Compensation Office SUBJECT: AUTHORIZATION OF SICK LEAVE AND/OR 100-DAY DIFFERENTIAL Please complete Sections III and IV and return a copy of this authorization form no later than __________________________ to those designated on the circulated copy list. Thank you. SECTION I: TO BE GENERATED / COMPLETED BY HUMAN RESOURCE SERVICES WHENEVER DAYTODAY ABSENCE EXCEEDS BEYOND THREE (3) MONTHS OR FOR CONSECUTIVE 100-DAY GRANT REQUEST Employee Name: ____________________________________________________________________ Social Security Number: _________________________________ o Classified Employeeo Certificated Employeeo Calendar_______o FTE: ________ Payroll: ____________________ Location: _____________________________________________ Number of Days Absent for __________ Fiscal Year as of ______________________ : _____________ Date Days Last Day Worked: _______________________ Physician's Statement(s) on File? o Yes o No (Attach Copies) Number of Accumulated Days/Hours: Sick___________________ Vacation___________________ Tentative End of Vacation: _________________________ Tentative End of 100-Day Differential: _________________________ ___________________________________________________ ________________________ Signature of Human Resource Services Representative(s) Date SECTION II: TO BE COMPLETED BY WORKERS COMPENSATION OFFICE Has Employee Filed Workers' Compensation Claim? o YesClaim Number: _____________________ o No Receiving Benefits at This Time? o Yes o No o Vocational Rehabilitation o Permanent Disability o Temporary Disability o Closed o Denied o Other: ____________________________________________ ___________________________________________________ ________________________ Signature of Workers' Compensation Representative Date SECTION III: TO BE COMPLETED BY HUMAN RESOURCE SERVICES Employee Status: o Day-to-Day Absence o Long-Term Board-Approved Leave of Absence Type: o Health Leave of Absence o Disability Leave of Absence Effective: __________________ Terminating: __________________ o Other ___________________________________________________JKM_j{|~;  8 : t v 2|"$DG  Gbd hL>* hLCJhLCJ OJQJ hL>* hL5hL59CJ(H*aJ(hL59B*aJphhL59B*\]aJphhL59CJ(aJ(hLjhLU?KLM|qf $x$Ifa$ukd8$$Ifl4\T(`@ @ @ (4 laf4 $$Ifa$ $$Ifa$$If01|}~; < $xx$Ifa$$a$ ! 0 0<Okd9$$Ifl40T( !(4 laf4 . v 2|P:{ ! !xdtckd9$$Ifl4&`'04 laf4p   FGHxp ${ !ckd:$$Ifl4&`'04 laf4p $xx$Ifa$ !<  <>ln~$fhjn~(6((())),*.*******P+R+++++,,,,- -$-D-F-J---.b//// 0B00000h_6 h_65U hLCJ hL5hL59B*aJph hLCJhLCJ OJQJhLNH~6(((|<d`wkd:$$Ifl4&`'  04 l` af4p ________________________ Signature of Human Resource Services Representative(s) Date SECTION IV: HUMAN RESOURCE SERVICES USE ONLY o Place Certificated or Classified Employee on 39-Month Reemployment Effective: __________________ Through: __________________ o Payment of Accumulated Sick Leave o Approved o Disapproved Effective: __________________ Through: __________________ o Payment of 100-Day Differential o Approved Differential o End Differential o Activate--Has Exhausted Differential Effective: __________________ Through: __________________ o Physician's Statement o Approved o Disapproved Comments: _______________________________ o Terminate Health Insurance Effective: __________________ ___________________________________________________ ________________________ Signature of Human Resource Services Representative(s) Date cc:Personnel AnalystDistribution by:Workers' Compensation OfficeHuman Resource ServicesPersonnel FileUpon Completion of All Three Sections 12/10/09; Rev. B PSL-F062 Page  PAGE 2 of  NUMPAGES 2 Important: All parties, please complete and route in a timely manner. ())))**,*v**N+P++T,,,--ckdU;$$Ifl4&`'04 laf4p $xx$Ifa$---D.F..b/d/l////// 0y`kd;$$Ifl4Fd'    4 laf4 $$Ifa$$If !x<d8gdL 0"0$0B000.`kd<$$Ifl4Fd'    4 laf4 $$Ifa$$If`kdm<$$Ifl4Fd'    4 laf40000111111111qljdkkd=$$Ifl\ (p  ` 4 la $$Ifa$$If  !`'gdL$a$ 00000000011 1 111111hL h_65CJh_6h_6CJmHnHujh_6CJU h_6CJ111/0PP&P/ =!8"8#$%@8Dd Z  S (A WSAC2"`b7=P ݨy7D20n7=P ݨyPNG  IHDR*0gAMA|Q pHYs\F\FCA78IDATxOy pV+h)J8O4@޷O[Himszh CI=Vwil.ΐz'SNRf?.R{%Hv*HGH!iKR%!sC_!飥H! 8* 3aɒFd*3#EQRmir4哚YAj?EVHݧH"}[I 9Jxi%tFtbeˀSf}4fD˞p%HOkIN$jͥ$f$B}čPIqB_4)69v]Jj>I O,1)IyrH$^,J'aPVҐ (ϐCsv 4)+YJ u>d ͊DuPLHKiZ$/ '13G8'RRH:Ax) 쬟' 8i\IeC8iT)JGIKڇ?$kI*+:A, G*\dw)RnXXZֻ)M-^vhR/r!FrF%"M^%y]&&%>v(/dya׏Wd^7NX{&ٽ̝VHJEr7 )Ir.7)=gnϨ{ $/TҞ$QL$)p+2Orn=}I$or7Mq'YEBh#'I[Hf,Qq4>rQ9 ^v8H\ /X[$ ! IAy!R bCV:"O}$GHkN!R:ϑh~ vĐH1"6)tN&>t͇z$)Ey+FQz1T[D$sNX.FpTfHL" J;IH] "$"5$/A)  $_&Ɉh6[ RzgHɹԷ(A$$TM &){yy=)$?R H ׇ7hW@H 2u:n#[,$ $oӘ=,DEYO)\ҴH"wpO L h9wdpooQcp8ZA}5q8 [HD,!)U%4{l1d$~&_C'EO.|! 'e@{q#ci]9%?MN%rgl9-+=u%㔨-ַEJS$If,)3Rܰ )Sv'Iց.3 $DJ:IΑIz/Ʀ/AʀGMpIF07m\:`-lddF[;r"G[9l#Y懳[jftOlhK)27H-A0HG³lS$ƍqKwhVU/Y]e As$X*GaY,啶,:M4)Pcu9M;6,5ϙU׎z&R=J;;~$,|6i ʯw0f0iďb)/qdKEK|$.#ƂEX;oϑ Ksv!]X,-Qqdmqp=d6)7>MYR3~XzrHF|..-)h5#KKw)p]@}DHD>G2 +#$.߀!IQxw!=g瑞RxaҭA2[K0y?$LB2#=^IFwo$[xR#U\Q_ɨ^ѣIɤ {%=>$>ѤT!OJMh rEh9"IS4$GHSHc5`xI#e?sIm6==]XeOvn`ӯi'HKNH ֺ<!%IS!RW-}H,Al.&8ie/CIܗJ1P9W&izHbHy/Jʞ}ヤ7~^li?$VDz)2'Tri&S/=K >΅C=*&e?c4u$4&fQҠѩҴʴٳ<4o0}=$ .բ,B 7"$ "n$O`OټaKPCn&DI4I_/`:ie#15Ie̅A) DBJfIZxhF9EWTf=n_txGI7_/`hM:QEr O+5Y7ElVͺ  ?*T*"T͖0c$$ _\BXx"5+WAC!HZ,;dA i\S$U}|:Eb&4e0<ܭ^J]ZE%HCy YmB*(G銗^`R'%ҍZ5]b.i٬eEj$wL>%!Y$v0IqX#"uKjRb$8wG,E;@$5$H&Mn^^S$]]{AW^Ip4CĆ3O6H%cߙײ-"Co$IT)Ҭ K/IIr]2ٳ1#I-LXz"u1R3C{ RY$IfKIvHyI].i%E0mMҝ6 XewQR[c_+8,gHk{="3H&&IC biZI߀+(ۇ6KdzK1w W ]`p묱pw>ٴ[IC4K% .*kgjr9]X,$AԘ=~o`HhkPÍN9ys1xͿ!I5~F,clA9B-[s]$ Gy9\Fnz;/[8k%W=b?-G/'Ų`z'~8YT̽ 3z_FK \;hza78>^q2]˜CqimKfſxyMz5HAyeI~XDݶi$V$CEw~dnXP#/NI|{UhRe=/Isјk=$Ț[+zZ'ԭ$||3N?!B7K(th݄O۫I  ㊭o`Rb:s#TP\6 AxkΧH\GT!iݰg-Hg"}ዴTO{ 9'H{Hω/E"}Ӥq_/_?TzrQEHAٮ?""='.?n/i4[vPE$t[yEWurh.i۳_gچ[cNϸib}qq_r(2ϓ%U`vIkc'#0$PD}t6HDԭ^FrXYg e|so53I-|sNۤ5&kca$ HҔg=xCҩ$I$#bؤ Ynש.&171$~ IO2$ou)@[$ kCFH,DMJ90HTblꙢK2;$o3FpE$U RfbI0=]zo`;Ic^< 'D=gD-]"Q:oהDʓ$O^ƵMy)҄CiJY诼ʺ6U/1LʯUbI#^;II/- ZHwH8'p4hNCH^R`/ $" ~ϦXI2φ8ΠNT+sĂb\/KCfs!l>1[6ո<糤.yzjד4n":$[ O&7jMbijJĺ1:S`}Y$Lj #5&i0F<C'\¯To*7Hv2I/==ou]^&&I0 4 Qe/,Os$rpߖoK#S[Ӓ"};얫~ ȏDu/ iG%y$&/ID\y.A$MgHKIH4#-Li!IO#3nԤAk|;JbzwA"D?MH\j+(ƛHz]F˱VRDvԚoSHItL$Ty$&Q ܳ!b!A~aLݰA3IrN;LH ErH:H_!m h,MQRF*]@jlRcrHۍ$kkH$klhR:gܐO$P6H)LRG ܚJV,y$'?B" hϸ, M_IC3;T_@=H"EbT4ORҚJf%$ ] 5ap4 Ͳ#ͅRi6I^ƕi[$.Si;N l"̿EjkKR;Ej4}4JS[4H,Qx,'c)y`؛T& iH7#cT뿗gX>I%4Iތ)u|*S&MGwxo& !xWC"٤©+ )q/<ORXII}N^RY ?W%HJCߗ%$o$.S$G>})ݥmɾ'MH}4-#۬3.IbaPiRYDZX 蝦$AciR$ҸF{S>=7f]iRH7,nGux bERwaO #u##TREHW-IIV~H6Ĉn) u@/>⸂\ҸAf̡IZXR9AS 7# jMMjۤwpfD&pZQ&qPiRrONd%53)M +U$$sa\qW-MMRVZ!ppe",%UX}/61.'N֥$9hR1EjtpqlH+R{41<#j5$&VkMsD?S(!ʧ6HXbeyE>!SwR[}rBY¤a$Q$ruD~|G=7>]A$'jqAhѸ$C+iݗ!qEbD 钘GCT\X3H/IjM*$_?I_IUT'HZ4ӉHnR$JJY$>@`9҄{p&i@}8!j%BϒfVRpR#~q$-+o6IC@]?(k}r:I-b>yuIP@k9sHjLxˏuSM>lhH Ԥ=I\-9D[g/aseE'd}ѭk /-ҬK"|̵Eol Ul‰J-+`T\idmb,ʕ_+z=4|2^\A"M#&8?B%8Hힿ8S1$ľH/=!~if皨8I_uy^+,|$t5I_dG]+5JpnH{5i {;JG2HHtWS־z>)Į'&]vttY;82#$HR{5# kyD[y.,ItOT 68t_JoWAҟv%u(Hbm ]$?HJמgp̝WWpAh)v/~('C]SrHMsa w0u%G~gHdp¼h$ǽXE#ׄ&~C$ՆCAX2ISrC:ޟm&IKj}$W&pIOqRIbiLx$&,=Cz$shA["iH&Y_|MHG2ϔd* "s哚$/ϑ)?`@A8Gv3eא^IYهIkg9A;R+ͤIfݔGꜣp㽗e8nU$ 7 zģs[I ^IS4 1Hk]L1RT"1sJ:,LZ Hpafen]S$i!yI]sm|"Y}ꦺGjrn/^$^nDfj$\&MIzN~~GI)&H INJΒϑT$q璄G?@D[׻F5NҤIζ4J"! ^,i,'Αb"/\^q\;AOG Jg$ Íl#9AYyYbԳZZںwUv.[B2ij*D9"Zby*'f5\$@Rn"MFLVS+L0M:xZVI Z -9g%Zb @jQ7|-ҬSIHp*IzY{U˼V}?"$.'gZd0*3Hpy?I&Jb^1L jIջGRSRHqxA g4oMqcD$8OR,[IKR9HRM"aIՀ&Ԕ"a0&'qDH8IciT$wi)ު"M9x)RkEFW 'Rἑu4:J @$BC)$$qEzi=(IĚ5ݤ`S I]Ûaƽ4twO`S5y%ݤ?㎑F$:*ꝤW%2.B)_~>x'M )q#>5Ѥ9/f$o˖3$V&snː$H!ew)SvUD{4e# $ugg"mR$}U#%3.EK"$nwV۪Ixm8\uTةMW|׻Bd@'0׼M7+W)ժ =@"qj{W3$ʻD*)R yg)KSI`}$&]}k`*gQ$)0 o[o%GKx$$9KѶĢj_pwőC^8HrPpӨ뚤\I& #5.i&F2KR&M]ջXV'&NTI-VcT#i݁iR& M"$& {(5$(L$cI^)K2Xƍn ; KX"ø⸛ջlJbͯK*b-R$5w-k4 >}R:N>פ#ʨHs4jn%Ej$6T jz. 3N$K$JVd9b@% ԤFnG3DO7kzרFZ&"[ֹ F 8M(WcUތr2SB0@})O8w ]:UȬFi$5|hrpWhA#$2I=2 !ΊԚJubau Ro7EE)0XԣTix\CUjO^&!O@ d9hd {;MRRL(9]v+ `e .RǀWD'k 5xDLSK/XKT-\j4H/T>oJ^.6i];њz @q^ 1Gjց>HU$I8>U'EԹ$iYe%aAjz}ڌ7H5 _'X4n}lxФ w2*[ImtW$[VI⩤q-;;;Lbwa ĝM0iLn*‡,")qg#.B`SI͓HwpcY!7LX0HA+c$q_#L1t_&҈$ۊAm@$nk1EIm@t_%W0ϩZLc]7Ewrqx)w%i Wtʗ Z+Ml[Mұo) 'I<+O:8zNoMƣy"+(ENr ҹ7=ڰIw<p.į!x-IOCp NC0' Sn8q XKH9zhIz&+TNg˶O9"q5)MLϴ7>(6[qc`ui$  mOOLmf-w&7۟(-V| |].[xe&+t"H[}j~Yh|O0L(ii4 NUГZt|l*櫽UH9YWdǀ@i|בW)ž|exKscRot_'d|x|OM ~m飤ؓo KI$b_{ghc@c8ufQN &RJ.B:s<WŤ]jϧIHJyan_M ]9]HN|iERN " eB:\s9)X wlW)m^O)]O&@ntF;#‹+ z$Q+HD1аLZ V*rIK&)Q\Śs'咄'rcx-ϐk-X]Esmqvc69"?`h$.#D.xɹ@z5d'Sh@ dbhD媌b$# EHk4O!:RsRLVt.Ksm7iy5>3E"}H_/E"}aH]"IENDB`$$If!vh55@ 5@ 5@ #v#v@ :V l4(+55@ / / 4f4l$$If!vh55!#v#v!:V l4(+55!4f4$$If!vh5`'#v`':V l405`'4f4p $$If!vh5`'#v`':V l405`'4f4p $$If!vh5`'#v`':V l4  05`'4` f4p $$If!vh5`'#v`':V l405`'4f4p $$If!vh555#v#v:V l455/  / 4f4$$If!vh555#v#v:V l455/  / 4f4$$If!vh555#v#v:V l455/ / 4f4$$If!vh5p5 5 5` #vp#v #v` :V l5p5 5` / 4<@< NormalCJ_HmH sH tH DAD Default Paragraph FontVi@V  Table Normal :V 44 la (k(No List 4@4 Header  !4 @4 Footer  !@Y@  Document Map-D OJQJH@"H  Balloon TextCJOJQJ^JaJ}>;<.Gl3h78tuv79qrs f g s t   0 1 2 y N O r   /  X Y ] o .012xyz{~0p 0p 0p 0p 0t 0 0 0 00x0000000000p 0t 00000000000000 00( 0, 00000000 0( 0, 000000000000x00 04 00000000000000000000 0x0 0 0 0 0 0 0 0 0 0 0 0 0@0 {0*@0@0 @0 @0 @0 @0 @0 {0tKLM|}~tu79qrs f g s t   0 1 2 y N O r   /  X Y ] o xy~{0  {00  ;0  {0  {0  ;0 {0  @HW ;0;0  (8 5;0  `88u  ;0 W ;0  ;0  ;0 9u , ;0 ;0 ;0 ;0 ;0 ;0 ;0 ;0 ;0 {0 ;0 ;0;0   0% ;0 ;0  ;0  ;0  ;0  ;0  ;0  ;0  ;0  ;0  ;0  ;0  ;0  ;0  ;0  ;0  ;0  ;0  ;0  ;0  ;0  ;0 ;0 ;0 \ ]   ;0  ;0  ;0  ;0 ;0  ;0  % % %| % %}{{0hK*@  ?01 | (- 0011 1!(*/:<!8@0(  B S  ?΀ ׾ ~ ~8*urn:schemas-microsoft-com:office:smarttagsdate 10122009DayMonthYear {~.;58j r 2 : O Y y  # 6 A AI{~333333333333333333333}~~ ; K g n -~ {~a6L_6KLM|}<8tu9qr  0 1  Y ] o 012xy~@HP LaserJet 5100 PCL 6LPT1:winspoolHP LaserJet 5100 PCL 6HP LaserJet 5100 PCL 6? od Xer.HP LaserJet 5100 PCL 62HxeP9/Q=c b_#"Nci%#L5j($~ٗ09wy7_kzneҵŵ|ILf.Y^:9j3 iDdMj'sG>Dvhôw!&xbx&p[Lz6mp3p@@ r+>D,ZF{~`m=ޠ:jJkT1h5\o^Er,'?N] qak)GI7PUNvI>,BF9ɘ=xS+~ .PHP LaserJet 5100 PCL 6? od Xer.HP LaserJet 5100 PCL 62HxeP9/Q=c b_#"Nci%#L5j($~ٗ09wy7_kzneҵŵ|ILf.Y^:9j3 iDdMj'sG>Dvhôw!&xbx&p[Lz6mp3p@@ r+>D,ZF{~`m=ޠ:jJkT1h5\o^Er,'?N] qak)GI7PUNvI>,BF9ɘ=xS+~ .P td... }0@0 00 @0000(UnknownGz Times New Roman5Symbol3& z Arial;Wingdings5& zaTahoma"VhS܆S܆S܆  $V24d 12VH(?a6$Authorization for Sick Leave/100 DayWord ProcessingSCUSDOh+'0  ( D P \ ht|(Authorization for Sick Leave/100 DayWord Processing Normal.dotɫͼ4Microsoft Word 10.0@0@ay@xCy@ay ՜.+,0 hp  ɫͼ  %Authorization for Sick Leave/100 Day Title !"#$%&'()*+,-./0123456789:;<=>?ABCDEFGHIJKLMNOPQRSTUVXYZ[\]^`abcdefiRoot Entry F oykData  >1Table@y,WordDocument1>SummaryInformation(WDocumentSummaryInformation8_CompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q