BLINN COLLEGE

REQUEST FOR USE OF SICK LEAVE FROM THE CATASTROPHIC INJURY OR ILLNESS FUND

TO:	Catastrophic Injury or Illness Fund Administrator

FROM:	(Employee) ID:

I request hours from the Catastrophic Injury or Illness Fund due to catastrophic illness/injury of (check one) myself or member of my immediate family as defined in the Catastrophic Injury or Illness policy. (COMPLETE THE REST OF THE FORM, SIGN BELOW AND SUBMIT THROUGH SUPERVISORY CHANNELS.)

Please provide the following additional information if the request is due to an illness/injury of a member of the employee's immediate family:

Name of the ill/injured individual:

Relationship to employee:

If the family member's residence is different from the employee's, give the location and a statement explaining how the family member is totally dependent on the employee for care and services on a continuing basis:

Is the illness/injury a result of an on-the-job accident?	YES	NO

Describe the catastrophic illness/injury. Attach additional pages, if necessary.

Attach a statement from the licensed physician of record which lists the specific nature of the illness or injury, prognosis, and expected recovery date for the employee. The licensed physician of record must also specify the Outlier threshold for the injury or illness as taken from the most current Federal Registry List of Diagnosis-Related Groups.

Time and date of employee's last day at work:

Anticipated date of employee's return to duty:

Attach a copy of the most current time and leave records information that reflects leave balances as of the employee's last day physically on duty.

Attach a copy of the Request for Leave of Absence form properly completed and signed.

Time and date all accrued leave will be exhausted:

EMPLOYEE'S SIGNATURE: ___________________________________________	DATE: _______________________

RECOMMENDATION FROM SUPERVISORY CHAIN: I recommend approval of the above request.

SIGNATURE	TYPE/PRINT NAME AND TITLE	DATE

Manager/Supervisor

Dean/Director

Vice President

President

McLENNAN COMMUNITY COLLEGE

MCC

2007-10-23

carol.estes

McLennan Community College