Form MS408 "State Employees Leave Bank Request Form" - Maryland

What Is Form MS408?

This is a legal form that was released by the Maryland Department of Budget and Management - a government authority operating within Maryland. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2021;
  • The latest edition provided by the Maryland Department of Budget and Management;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MS408 by clicking the link below or browse more documents and templates provided by the Maryland Department of Budget and Management.

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Download Form MS408 "State Employees Leave Bank Request Form" - Maryland

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STATE EMPLOYEES LEAVE BANK REQUEST FORM
TO BE COMPLETED BY EMPLOYEE
(Please TYPE or PRINT)
W#*:
Agency Hire Date:
Name*:
Personal Email:
* Your full Name and Workday Number (W#) are required to help verify your identity and
process your Request. Failure to provide it may result in delays and/or rejection of your request.
State Hire Date:
Job Title and brief description of duties:
Home Address:
City/State/Zip:
Request Type:
New
Extension
Updated
Full Agency Name:
Signature:
Date:
TO BE COMPLETED BY AGENCY HR/LEAVE BANK COORDINATOR
Leave Bank Coordinator:
Email:
Phone #:
Fax #:
Last Date Employee Worked:
Leave Bank Membership Expiration Date**:
Hours Needed: __________ Hrs
Dates to Cover: From
Through
Can agency accommodate a modified duty assignment? No
Yes
Is employee on FMLA leave? No
Yes
If Yes, provide end date of current FMLA:
Has employee been on one-day sick slip restriction within the last two years? No
Yes
If Yes, provide effective date of restriction:
Has employee been disciplined within the last year? No
Yes
If Yes, provide effective date of disciplinary action:
Employee’s last performance evaluation rating was:
Satisfactory or Above
Less than Satisfactory
If Yes, Contact DBM Leave Bank Program Manager
Is this absence due to an on-the-job injury? No
Yes
Has the employee been seen by the State Medical Director? No
Yes
If Yes, Provide copy of Medical Report
Has the employee applied for Disability Retirement? No
Yes
If Yes, Provide copy of signed SRA 129
Leave Bank Coordinator’s Signature:
Date:
**COPY OF MOST CURRENT LEAVE BANK MEMBERSHIP FORM IS REQUIRED
COMPLETED BY APPOINTING AUTHORITY OR DESIGNEE
This employee has exhausted all forms of annual, sick, personal and compensatory time because of a serious and
prolonged medical condition. The employee has been a member of the Leave Bank for at least 90 days or has been
granted an exemption by the Secretary of Budget and Management. Approval will not cause the employee to exceed
2,080 hours of leave from the Leave Bank and Employee-to-Employee Leave Donation Programs during his/her entire
State employment. Approval will not cause the employee to exceed 16 months of continuous leave, when combined
with all other forms of paid leave. As the appointing authority for this employee, I have reviewed the employee’s
records and I certify that this request meets all of the criteria specified in this Section.
_________________________
______________________________________________________________
Signature of Appointing Authority or Designee
Date
MS 408
(Rev. 7/2021)
STATE EMPLOYEES LEAVE BANK REQUEST FORM
TO BE COMPLETED BY EMPLOYEE
(Please TYPE or PRINT)
W#*:
Agency Hire Date:
Name*:
Personal Email:
* Your full Name and Workday Number (W#) are required to help verify your identity and
process your Request. Failure to provide it may result in delays and/or rejection of your request.
State Hire Date:
Job Title and brief description of duties:
Home Address:
City/State/Zip:
Request Type:
New
Extension
Updated
Full Agency Name:
Signature:
Date:
TO BE COMPLETED BY AGENCY HR/LEAVE BANK COORDINATOR
Leave Bank Coordinator:
Email:
Phone #:
Fax #:
Last Date Employee Worked:
Leave Bank Membership Expiration Date**:
Hours Needed: __________ Hrs
Dates to Cover: From
Through
Can agency accommodate a modified duty assignment? No
Yes
Is employee on FMLA leave? No
Yes
If Yes, provide end date of current FMLA:
Has employee been on one-day sick slip restriction within the last two years? No
Yes
If Yes, provide effective date of restriction:
Has employee been disciplined within the last year? No
Yes
If Yes, provide effective date of disciplinary action:
Employee’s last performance evaluation rating was:
Satisfactory or Above
Less than Satisfactory
If Yes, Contact DBM Leave Bank Program Manager
Is this absence due to an on-the-job injury? No
Yes
Has the employee been seen by the State Medical Director? No
Yes
If Yes, Provide copy of Medical Report
Has the employee applied for Disability Retirement? No
Yes
If Yes, Provide copy of signed SRA 129
Leave Bank Coordinator’s Signature:
Date:
**COPY OF MOST CURRENT LEAVE BANK MEMBERSHIP FORM IS REQUIRED
COMPLETED BY APPOINTING AUTHORITY OR DESIGNEE
This employee has exhausted all forms of annual, sick, personal and compensatory time because of a serious and
prolonged medical condition. The employee has been a member of the Leave Bank for at least 90 days or has been
granted an exemption by the Secretary of Budget and Management. Approval will not cause the employee to exceed
2,080 hours of leave from the Leave Bank and Employee-to-Employee Leave Donation Programs during his/her entire
State employment. Approval will not cause the employee to exceed 16 months of continuous leave, when combined
with all other forms of paid leave. As the appointing authority for this employee, I have reviewed the employee’s
records and I certify that this request meets all of the criteria specified in this Section.
_________________________
______________________________________________________________
Signature of Appointing Authority or Designee
Date
MS 408
(Rev. 7/2021)