Attachment 1 "DJJ Sick Leave Donation/ Transfer Request to Use Form" - Florida

What Is Attachment 1?

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

Form Details:

  • Released on June 1, 2018;
  • The latest edition provided by the Florida Department of Juvenile Justice;
  • 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 Attachment 1 by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download Attachment 1 "DJJ Sick Leave Donation/ Transfer Request to Use Form" - Florida

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Attachment 1
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
DJJ SICK LEAVE DONATION/ TRANSFER REQUEST TO USE FORM
Part I – Request to Use Donated Sick Leave
I certify that I have suffered an accident, childbirth, illness, or injury. I understand that I must exhaust all of my personal leave credits,
with the exception of my personal holiday; to request to use donated sick leave credits to cover my absences. I understand that it is my
responsibility to read and adhere to the Sick Leave Donation/Transfer Policy and Procedure. I will ensure that the Bureau of Human
Resources receive all required documents necessary to approve my request, two (2) business days prior to payroll deadline. In the event
of an untimely notification of return to work, I may receive a salary overpayment letter and will be required to repay sick leave credits I
was not entitled. I understand that I may solicit sick leave donations from co-workers, family and friends within DJJ, as well as from other
agencies that participate in the Sick Leave Donation/Transfer Plan.
I authorize my employer to use my name and release a general description of the medical circumstances in order to determine my
eligibility in accessing this benefit.
Date Absence Began or Will Begin: ______/______/_______ Signed: ______________________________ Date: ______/_____/_______
Signer must check where applicable:
Self
Spouse
Other authorized person representing employee
Part II – Medical Documentation
THE FOLLOWING IS CONFIDENTIAL MEDICAL INFORMATION
Based on my current accident, childbirth, illness, or injury, I am applying for donated sick leave credits from my employer’s Sick Leave
Donation/Transfer Plan. I hereby authorize any healthcare practitioner who has examined me with respect to my current accident,
childbirth, illness, or injury, to complete and answer any relevant questions that may be asked by the Sick Leave Donation/Transfer Plan
Coordinator in order to determine my eligibility for this benefit.
Employee’s Signature: _______________________________________________________ Date: __________/__________/_________
Employee’s Name (Print): ____________________________________________________
People First User ID#: _________________
Supervisor’s Signature: ______________________________________________________
Date: _________/__________/__________
Part III - To Be Completed by Treating Healthcare Provider Only
Print Healthcare Provider’s Name: _______________________________________ Business Telephone: ( ) _____________________
Mailing Address: ________________________________________________________________________________________________
Date of which patient was first examined for current condition: ___________/_________/____________
Patient’s condition is due to:
Accident
Childbirth
Illness
Injury
(please check one)
Date patient is expected to recover or be released to duty: _______/_______/________ Check one:
Part-time
Full-time
If part-time, what are the following restrictions: ________________________________________________________________________
Signature of treating healthcare provider: ___________________________________ State/License Number: ______________________
Return this form (marked confidential) to the Department of Juvenile Justice, Bureau of Human Resources, 2737 Centerview Drive,
Tallahassee, Florida 32399-3100 or you may fax to 850-921-6700.
INSTRUCTIONS FOR AUTHORIZED USE OF THIS FORM: In order for the patient to comply with the eligibility requirements, the treating
healthcare provider must complete this form and return it to the patient’s employer directly or the patient.
Revised 06/2018
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Attachment 1
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
DJJ SICK LEAVE DONATION/ TRANSFER REQUEST TO USE FORM
Part I – Request to Use Donated Sick Leave
I certify that I have suffered an accident, childbirth, illness, or injury. I understand that I must exhaust all of my personal leave credits,
with the exception of my personal holiday; to request to use donated sick leave credits to cover my absences. I understand that it is my
responsibility to read and adhere to the Sick Leave Donation/Transfer Policy and Procedure. I will ensure that the Bureau of Human
Resources receive all required documents necessary to approve my request, two (2) business days prior to payroll deadline. In the event
of an untimely notification of return to work, I may receive a salary overpayment letter and will be required to repay sick leave credits I
was not entitled. I understand that I may solicit sick leave donations from co-workers, family and friends within DJJ, as well as from other
agencies that participate in the Sick Leave Donation/Transfer Plan.
I authorize my employer to use my name and release a general description of the medical circumstances in order to determine my
eligibility in accessing this benefit.
Date Absence Began or Will Begin: ______/______/_______ Signed: ______________________________ Date: ______/_____/_______
Signer must check where applicable:
Self
Spouse
Other authorized person representing employee
Part II – Medical Documentation
THE FOLLOWING IS CONFIDENTIAL MEDICAL INFORMATION
Based on my current accident, childbirth, illness, or injury, I am applying for donated sick leave credits from my employer’s Sick Leave
Donation/Transfer Plan. I hereby authorize any healthcare practitioner who has examined me with respect to my current accident,
childbirth, illness, or injury, to complete and answer any relevant questions that may be asked by the Sick Leave Donation/Transfer Plan
Coordinator in order to determine my eligibility for this benefit.
Employee’s Signature: _______________________________________________________ Date: __________/__________/_________
Employee’s Name (Print): ____________________________________________________
People First User ID#: _________________
Supervisor’s Signature: ______________________________________________________
Date: _________/__________/__________
Part III - To Be Completed by Treating Healthcare Provider Only
Print Healthcare Provider’s Name: _______________________________________ Business Telephone: ( ) _____________________
Mailing Address: ________________________________________________________________________________________________
Date of which patient was first examined for current condition: ___________/_________/____________
Patient’s condition is due to:
Accident
Childbirth
Illness
Injury
(please check one)
Date patient is expected to recover or be released to duty: _______/_______/________ Check one:
Part-time
Full-time
If part-time, what are the following restrictions: ________________________________________________________________________
Signature of treating healthcare provider: ___________________________________ State/License Number: ______________________
Return this form (marked confidential) to the Department of Juvenile Justice, Bureau of Human Resources, 2737 Centerview Drive,
Tallahassee, Florida 32399-3100 or you may fax to 850-921-6700.
INSTRUCTIONS FOR AUTHORIZED USE OF THIS FORM: In order for the patient to comply with the eligibility requirements, the treating
healthcare provider must complete this form and return it to the patient’s employer directly or the patient.
Revised 06/2018
Clear Form
Save As..
Print