"Catastrophic Leave Bank Program Application for Medical Emergency Due to Illness/Injury Purposes" - Arkansas

Catastrophic Leave Bank Program Application for Medical Emergency Due to Illness/Injury 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 June 15, 2018;
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Download "Catastrophic Leave Bank Program Application for Medical Emergency Due to Illness/Injury Purposes" - Arkansas

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Department of Finance and Administration - Office of Personnel Management
Catastrophic Leave Bank Program Application for Medical Emergency
Print Form
due to Illness/Injury Purposes
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 a medical emergency due to illness/injury. Type or print
legibly and attach all required documentation. Provide the completed application and applicable requirement to your supervisor.
NOTE: The award of catastrophic leave for medical emergency 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
Name of Patient
Relationship to Employee
Patient's date of birth
Applicant Certification: (Check the appropriate response for each statement.) I certify:
1. I am requesting catastrophic leave for a medical emergency due to illness/injury purposes as stated on the
Yes
No
Physician's Certification.
2. I will have exhausted all paid accrued leave before using approved catastrophic leave for the medical emergency.
Yes
No
3. I expect to be absent from work without paid leave due to this medical emergency.
Yes
No
4. I had at least 80 hours of combined sick and annual leave at the onset of this medical emergency or I have attached
No
Yes
the required documentation to request an "extraordinary circumstance" waiver of the 80 hours.
Yes
No
5. I am eligible for retirement or social security/social security disability benefits.
6. I have applied for retirement benefits;
date of application.
Yes
No
7. I have applied for social security/social security disability benefits;
date of application.
Yes
No
8. I am receiving social security/social security disability benefits;
date benefits began
Yes
No
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 will not accrue annual or sick leave while receiving catastrophic leave for the medical emergency during a period of 10 or more days in a month.
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.
.
Any unused catastrophic leave for the maternity purpose stated above shall be returned to the OPM Catastrophic Leave Bank
I will forfeit the catastrophic leave benefits if I terminate my employment or my employment is terminated.
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 will have my approved catastrophic leave due to illness/injury run concurrently with the Family and Medical Leave Act (FMLA) provisions, if eligible.
The recommendations of the OPM Catastrophic Leave Bank Committee or the State Personnel Administrator are not subject to grievance, arbitration or litigation.
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 Catastrophic Leave
If Designee, State Relationship
Date
for a Medical Emergency
Page 1 of 2
OPM R 6/15/2018
Department of Finance and Administration - Office of Personnel Management
Catastrophic Leave Bank Program Application for Medical Emergency
Print Form
due to Illness/Injury Purposes
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 a medical emergency due to illness/injury. Type or print
legibly and attach all required documentation. Provide the completed application and applicable requirement to your supervisor.
NOTE: The award of catastrophic leave for medical emergency 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
Name of Patient
Relationship to Employee
Patient's date of birth
Applicant Certification: (Check the appropriate response for each statement.) I certify:
1. I am requesting catastrophic leave for a medical emergency due to illness/injury purposes as stated on the
Yes
No
Physician's Certification.
2. I will have exhausted all paid accrued leave before using approved catastrophic leave for the medical emergency.
Yes
No
3. I expect to be absent from work without paid leave due to this medical emergency.
Yes
No
4. I had at least 80 hours of combined sick and annual leave at the onset of this medical emergency or I have attached
No
Yes
the required documentation to request an "extraordinary circumstance" waiver of the 80 hours.
Yes
No
5. I am eligible for retirement or social security/social security disability benefits.
6. I have applied for retirement benefits;
date of application.
Yes
No
7. I have applied for social security/social security disability benefits;
date of application.
Yes
No
8. I am receiving social security/social security disability benefits;
date benefits began
Yes
No
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 will not accrue annual or sick leave while receiving catastrophic leave for the medical emergency during a period of 10 or more days in a month.
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.
.
Any unused catastrophic leave for the maternity purpose stated above shall be returned to the OPM Catastrophic Leave Bank
I will forfeit the catastrophic leave benefits if I terminate my employment or my employment is terminated.
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 will have my approved catastrophic leave due to illness/injury run concurrently with the Family and Medical Leave Act (FMLA) provisions, if eligible.
The recommendations of the OPM Catastrophic Leave Bank Committee or the State Personnel Administrator are not subject to grievance, arbitration or litigation.
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 Catastrophic Leave
If Designee, State Relationship
Date
for a Medical Emergency
Page 1 of 2
OPM R 6/15/2018
Department of Finance and Administration - Office of Personnel Management
Catastrophic Leave Bank Program Application for Medical Emergency
due to Illness/Injury Purposes
OPM Case #
Employee's Name (Last, First)
Personnel Number
Part II - Supervisory Verification: (To be completed by employee's supervisor.)
has not
From the date of this application, the employee
received a documented disciplinary action for leave abuse during
has
the last one (1) year period.
Date
Agency Supervisor's Name/Signature
Position Title
Work Phone
Part III - Human Resources Verification: (To be completed by the agency human resources officer or designee regarding the employee.)
Class Code
Position Title
Pay Grade
Position #
Full-time
Yes
No
Hourly Rate of Pay
Career Service Date
Latest Hire Date
Last Day Worked
Date of Birth
Total catastrophic leave hours requested
Date employee will begin Leave Without Pay (LWOP)
Beginning Date of Approved Catastrophic Leave
Expected ending date of Approved Catastrophic Leave
Applicant applied for and was awarded shared leave for this event during the past one (1)
Shared Leave Benefits:
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?
/
Applicant applied for catastrophic leave for maternity purposes during
Catastrophic Leave for Maternity Purposes:
No
Yes
the past one (1) year period.
If yes, how many hours of catastrophic leave were awarded/used by the applicant?
/
Applicant applied for/was receiving Workers' Compensation during the past one
Workers' Compensation Benefits:
No
Yes
(1) year period.
If yes, what is the status of the application?
Pending
Denied
Applied
Approved
Date Worker's Comp began
Expected Duration
Amount of workers' comp weekly 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?
No
Will the approved catastrophic leave run concurrently
Yes
with FMLA leave?
Yes
No
If no, explain:
Position Title
Work Phone
Agency Human Resources Officer's or Designee's Name/Signature
Date
Part IV - Agency Director or Designee Verification: (To be completed by agency director or his/her designee)
I certify the employee's application for catastrophic leave due to a medical emergency is appropriate and the information and supporting
documentation provided by the agency is complete and correct.
Date
Signature of Agency Director/Designee
If Designee, State Title
OPM R 6/15/2018
Page 2 of 2
Medical Emergency due to Illness/Injury Purposes
OPM Case #
Personnel Number
Employee's Name (Last, First)
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
Projected Ending Date
Beginning Date
Total Hours Awarded
Total dollar value of leave awarded
Date
DFA OPM Coordinator's or Designee's Name/Signature
Work Phone
Part V - DFA OPM State Personnel Administrator Review and Remarks (To be completed by State Personnel Administrator)
I concur with the Committee's recommendation.
I request Committee reconsider its recommendation.
DFA OPM State Personnel Administrator's Signature
Date
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
OPM R 6/15/2018
Page 3 (Supplement to pages 1 and 2
Page of 3