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Shared Leave Request Form
All information will be submitted on a secured server for confidentiality.
Shared leave will only be granted for serious, extreme, or life-threatening illnesses, injuries, impairments or physical or mental conditions which have caused, or are likely to cause, the employee to take leave without pay or terminate employment. Shared leave will not be granted for common or minor illnesses, injuries, impairments, or physical or mental conditions.
Request is for: Self Family Member
If family member, state name and relationship to employee:
Describe and provide any necessary information that would help in concluding that the illness, injury, impairment or physical or mental condition is serious, extreme or life-threatening:
Are you currently receiving Worker's Compensation? YesNo
Have you applied for Worker's Compensation? YesNo
If yes, what date did you apply?
Are you currently receiving Long-Term Disability payments? YesNo
Have you applied for Long-term Disability payments? YesNo
I certify that I understand, agree to, and meet the requirements and conditions of the Shared Leave Program as authorized in K.A.R. 1-9-23. I authorize the Appointing Authority or the Shared Leave Review Committee to obtain any necessary information regarding my request for Shared Leave. I understand that denial of this application is not subject to appeal to the Civil Service Board.
By submitting this application you are certifying that you are the person named on the application. Further that any and all information contained on the application form is complete and accurate. Any material misrepresentation or inaccuracies may result in denial of eligibility or other sanctions.
If you have any questions about completing this form or Shared Leave, contact Joyce Boeschen at 913-588-5147.