Spreadsheet: a8657334-b05a-41dc-8eac-5eef6eb18134
Sheet: Sheet1

Please type or print legibly. | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Case # | Unnamed: 7
INSTRUCTIONS |  |  |  |  |  | NOTE
Complete this form to apply for Catastrophic Leave Time. Attach all appropriate documentation of the medical emergency. Include the Physician's Certification for Catastrophic Leave and the Catastrophic Leave Bank (CLB) Liability Agreement. Present forms to your supervisor. |  |  |  |  |  | The award of [NAME] is dependent upon its availability within the Catastrophic Leave Bank. The program does not create any expectation or promise of continued employment.
Part I - Application and Certification (To be completed by applicant employee or designee on his/her behalf).
Patient Name (Last, First, Middle Initial) |  |  |  |  |  | Relationship to Employee
List qualifying family member(s) employed by the state:
Name |  |  | Agency |  |  | Social Security Number
Employee Name (Last, First, Middle Initial) |  |  |  | Position Number |  | Social Security Number
Class Code of Position |  | Position Title |  |  |  | Grade | [NAME]
Agency/Institution |  |  | Work Phone Number |  | Home Phone Number |  | Birthday: YY/MM/DD
Retirement and Social Security/Social Security Disability Benefits
 | I am eligible for Retirement or Social Security benefits.
 | I have applied for Retirement. If yes, date applied |  |  |  |  | .
 | I have applied for Social Security Disability. If yes, date applied |  |  |  |  |  | .
Certification: (If certifying on behalf of employee, modify as appropriate.) I certify that: |  |  |  |  |  | 5.
1. I have been affected by a medical emergency described on the attached Physician's Certification.
2. I have or will have exhausted all Leave and Compensatory Time as of the date indicated above. |  |  |  |  |  | 6.
3. I expect to be absent from work without paid leave because of this medical emergency.
4. I had at least 80 hours of combined sick and annual leave at the onset of this illness/injury. |  |  |  |  |  | 7.
Signature of Employee Receiving Catastrophic Leave or His/Her Designee |  |  |  | If [NAME], state your relationship to Recipient |  |  | Date
Part II - Supervisory Verification (To be completed by Applicant's [NAME].)
Disciplinary Action for Leave Abuse During past 2 years? | Explain why this employee's leave has been exhausted. Be specific:
Could this job be restructured temporarily to allow employee to return to work at an earlier date?
 |  |  |  |  |  | If Yes, attach revised job duties.
Signature of Supervisor |  | Position Title |  |  | Phone Number |  | Date
Signature of Budget Officer |  |  |  | Signature of Director
Page 2
Employee Name (Last, First, Middle Initial) |  |  |  |  |  | Social Security Number
Part III - Personnel/Payroll Verification (To be completed by Agency Personnel/Payroll Officer.)
Full-Time | Career Service Date |  | Latest Hire Date |  | Date  Employee Would Go On LWOP |  | Case Number
Date Leave Exhausted - Attach Leave Calendar(s) |  |  | Amount of Catastrophic Leave Requested |  |  | Duration Dates of Catastrophic Leave
(Includes Annual, Sick, Holiday and Comp-Verified by Timekeeper)
Date | Time |  | Last Day Worked |  | Total Hours Requested In one (1) hour increments | Beginning Date | Projected Ending Date
Timekeeper's Name (Print) |  |  | Timekeeper's Signature |  |  | Phone Number | Date
WORKER'S COMPENSATION STATUS
Applied | Date | Approved? | Date | Pending? |  | Denied? | Date
Amount of Workers' Compensation Weekly Benefits |  |  | Hourly Rate on Date of Accident |  |  | Hours of Catastrophic Leave Requested Weekly
Date Workers' Compensation Commenced |  |  | Expected Duration |  |  | Date
DISABILITY INSURANCE (FOR INSTITUTION EMPLOYEES ONLY)
Does institution provide Employee Disability Insurance?* |  |  | Has employee filed for coverage? |  | Date Insurance begins/#of Months required for eligibility
Signature of Authorized Agency/Institution Representative |  |  |  | Position Title |  |  | Phone Number
Part IV - Catastrophic Leave Committee Review and Recommendation
Date Received | Date Reviewed |  |  | Dates of Duration of Approved Catastrophic Leave
 |  |  |  | Beginning Date |  | Projected Ending Date
APPLICATION APPROVED | Total Hours Awarded |  |  | Total Dollar Value of Leave Received |  | INSTRUCTIONS After review, recommendation and signature of Committee Chairperson forward to Agency Director for final review and consideration of recommendation.
Signature of CLB Committee Chairperson/Designee |  |  |  | Date
Part V - Director's Review and Action |  |  |  | FINAL ACTION
Signature of Agency Director |  |  |  | Name of Agency |  |  | Date
 |  |  |  | Part VI - Completed by CLB [NAME]
Return originals to:
OPM Catastrophic Leave Bank
1509 West Seventh, [NAME] 201 - DFA Building |  |  |  | Signature of CLB [NAME] |  |  | Date Entered
[NAME] 3278
Little Rock, AR 72203-3278
 |  | 0905 (R5/99)
*Institution may provide Disability Insurance at no cost employee.