"Catastrophic Leave Bank Program Application for Maternity Purposes" - Arkansas

Catastrophic Leave Bank Program Application for Maternity Purposes is a legal document that was released by the Arkansas Department of Finance & Administration - a government authority operating within Arkansas.

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  • Released on May 1, 2017;
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Download "Catastrophic Leave Bank Program Application for Maternity Purposes" - Arkansas

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Department of Finance and Administration - Office of Personnel Management
Catastrophic Leave Bank Program Application for Maternity Purposes
Print Form
Authorized by ACA §§ 21-4-203, 21-4-209, 21-4-214
OPM Case #
Instructions: Please complete this form to apply for catastrophic leave for maternity purposes. Type or print legibly. Note: the
requirements by each maternity purpose below. Provide the completed application and applicable requirement to your supervisor.
NOTE: The award of catastrophic leave for maternity purposes is based on the availability of donated leave within the OPM
Catastrophic Leave Bank and the employee's eligibility for and compliance with law, policy and procedure.
Part I - Application and Certification: (To be completed by employee or designee on the employee's behalf.)
Employee's Name (Last, First)
Personnel Number
Agency Number and Name
Work Phone
Home Address
Home/Cell Phone
Home e-mail address
Applicant Certification: (Check the appropriate box.)
I certify I am requesting catastrophic leave for maternity purposes due to:
1.
The birth of my biological child. (Applicant must provide agency HR officer acceptable proof of actual date of birth.)
2. The placement of an adoptive child in my home. (Applicant must provide agency HR officer acceptable proof of placement date.)
I understand and agree with the following:
I have been employed with state government for at least one (1) year in a regular, full-time position.
I am not required to exhaust annual or sick leave before being granted catastrophic leave for the maternity purpose stated above.
I will not accrue annual or sick leave while receiving catastrophic leave for the maternity purpose stated above for the month the catastrophic
leave begins.
If, during the period the employee is in a catastrophic leave status, any birthday or holiday leave is accrued, it will be removed and reflected as
catastrophic leave.
I may be granted up to four (4) consecutive weeks of catastrophic leave with pay within the first twelve (12) weeks after the birth of my biological
child or placement of an adoptive child in my home.
After the expiration of the four (4) weeks of catastrophic leave for either maternity purpose above, maternity leave shall be treated as any other
leave for sickness or disability per ACA § 21-4-209.
I will forfeit the catastrophic leave benefits if I terminate my employment or my employment is terminated.
I will have my approved catastrophic leave for maternity purposes run concurrently with the Family and Medical Leave Act (FMLA) provisions, if
eligible.
I will comply with the provisions of law, policy and procedure; if verified abuse, misrepresentation or fraud is found, I shall repay all of the leave
hours awarded me from the OPM Catastrophic Leave Bank and be subject to disciplinary action up to and including termination.
I have not applied for and am not receiving social security disability benefits.
Any unused catastrophic leave for the maternity purpose stated above shall be returned to the OPM Catastrophic Leave Bank.
I consent to the encrypted electronic distribution of this document within and outside the agency for the purpose of completion, consideration
and determination by my agency and DFA-OPM.
Signature of Employee/Designee Requesting
Date
If Designee, State Relationship
Catastrophic Leave for Maternity Purposes
Part II - Supervisory Verification: (To be completed by employee's supervisor.)
I am aware this employee
eligible to apply for catastrophic leave for maternity purposes from the date of this
will be
is
application.
Work Phone
Agency Supervisor's Name/Signature
Position Title
Date
Page 1 of 2
OPM R 5/1/2017
Department of Finance and Administration - Office of Personnel Management
Catastrophic Leave Bank Program Application for Maternity Purposes
Print Form
Authorized by ACA §§ 21-4-203, 21-4-209, 21-4-214
OPM Case #
Instructions: Please complete this form to apply for catastrophic leave for maternity purposes. Type or print legibly. Note: the
requirements by each maternity purpose below. Provide the completed application and applicable requirement to your supervisor.
NOTE: The award of catastrophic leave for maternity purposes is based on the availability of donated leave within the OPM
Catastrophic Leave Bank and the employee's eligibility for and compliance with law, policy and procedure.
Part I - Application and Certification: (To be completed by employee or designee on the employee's behalf.)
Employee's Name (Last, First)
Personnel Number
Agency Number and Name
Work Phone
Home Address
Home/Cell Phone
Home e-mail address
Applicant Certification: (Check the appropriate box.)
I certify I am requesting catastrophic leave for maternity purposes due to:
1.
The birth of my biological child. (Applicant must provide agency HR officer acceptable proof of actual date of birth.)
2. The placement of an adoptive child in my home. (Applicant must provide agency HR officer acceptable proof of placement date.)
I understand and agree with the following:
I have been employed with state government for at least one (1) year in a regular, full-time position.
I am not required to exhaust annual or sick leave before being granted catastrophic leave for the maternity purpose stated above.
I will not accrue annual or sick leave while receiving catastrophic leave for the maternity purpose stated above for the month the catastrophic
leave begins.
If, during the period the employee is in a catastrophic leave status, any birthday or holiday leave is accrued, it will be removed and reflected as
catastrophic leave.
I may be granted up to four (4) consecutive weeks of catastrophic leave with pay within the first twelve (12) weeks after the birth of my biological
child or placement of an adoptive child in my home.
After the expiration of the four (4) weeks of catastrophic leave for either maternity purpose above, maternity leave shall be treated as any other
leave for sickness or disability per ACA § 21-4-209.
I will forfeit the catastrophic leave benefits if I terminate my employment or my employment is terminated.
I will have my approved catastrophic leave for maternity purposes run concurrently with the Family and Medical Leave Act (FMLA) provisions, if
eligible.
I will comply with the provisions of law, policy and procedure; if verified abuse, misrepresentation or fraud is found, I shall repay all of the leave
hours awarded me from the OPM Catastrophic Leave Bank and be subject to disciplinary action up to and including termination.
I have not applied for and am not receiving social security disability benefits.
Any unused catastrophic leave for the maternity purpose stated above shall be returned to the OPM Catastrophic Leave Bank.
I consent to the encrypted electronic distribution of this document within and outside the agency for the purpose of completion, consideration
and determination by my agency and DFA-OPM.
Signature of Employee/Designee Requesting
Date
If Designee, State Relationship
Catastrophic Leave for Maternity Purposes
Part II - Supervisory Verification: (To be completed by employee's supervisor.)
I am aware this employee
eligible to apply for catastrophic leave for maternity purposes from the date of this
will be
is
application.
Work Phone
Agency Supervisor's Name/Signature
Position Title
Date
Page 1 of 2
OPM R 5/1/2017
Department of Finance and Administration - Office of Personnel Management
Catastrophic Leave Bank Program Application for Maternity Purposes
OPM Case #
Employee's Name (Last, First)
Personnel Number
Part III - Human Resources Verification: (To be completed by the agency human resources officer or designee regarding the employee.)
Position Title
Class Code
Pay Grade
Position #
Full-time
Yes
No
Career Service Date
Hourly Rate of Pay
Latest Hire Date
Last Day Worked
Date of Birth
Beginning date of approved catastrophic leave for maternity purposes
Expected ending date
Total hours requested
Proof of birth or placement has been provided:
Yes
No
Shared Leave Benefits:
Applicant applied for and was awarded shared leave for this event during the past one (1)
Yes
No
year period.
If yes, how many hours of shared leave were used by the applicant:
Catastrophic Leave for Illness/Injury Benefits:
Applicant applied for catastrophic leave for illness/injury during the
Yes
No
past one (1) year period.
If yes, how many hours of catastrophic leave were awarded/used by the applicant?
/
Catastrophic Leave for Maternity Purposes:
Applicant applied for catastrophic leave for maternity purposes during
Yes
No
the past one (1) year period.
If yes, how many hours of catastrophic leave were awarded/used by the applicant?
/
Workers' Compensation Benefits:
Applicant applied for/was receiving Workers' Compensation during the past one
Yes
No
(1) year period.
If yes, what is the status of the application?
Applied
Pending
Approved
Denied
Date workers' comp began
Expected duration
Amount of workers' comp benefits
Hourly rate of pay on date of accident?
In conjunction with workers' comp benefits, how many hours of catastrophic leave for maternity purposes are needed weekly?
FMLA: Has the applicant applied for family and medical leave?
Will the approved catastrophic leave run concurrently
Yes
No
with FMLA leave?
Yes
No
If no, explain:
Work Phone
Date
Position Title
Agency Human Resources Officer's or Designee's Name/Signature
Part IV - Agency Director or Designee Verification: (To be completed by the agency director or designee.)
I certify the employee's application for catastrophic leave due to the designated maternity purpose is appropriate and the information provided
by the agency is complete and correct.
Date
Signature of Agency Director/Designee
If Designee, State Title
Page 2 of 2
OPM R 5/1/2017
Employee's Name (Last, First)
Personnel Number
OPM Case #
MATERNITY PURPOSES
Part V - DFA OPM Catastrophic Leave Bank Program Review and Determination:(To be completed by DFA OPM Coordinator or designee.)
Date received
Date reviewed
Application Approved:
Yes
No
Pending
Beginning Date
Projected ending date
Total hours awarded
Total dollar Value of leave awarded:
$
Reason for denial/pending:
Date
Work Phone
DFA OPM Coordinator's or Designee's Signature
Part VI- Record Keeping: (To be completed by DFA OPM Coordinator or designee.)
Date recorded to file
Date sent to applicant/agency
Recorder's initials
Supplement to Catastrophic Leave Application for maternity purposes.
OPM R 5/1/2017
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