ࡱ> 685 bjbj 4  .t,T1YpZG*jI0.QYYm$. :   PORTLAND COMMUNITY COLLEGE DISTRICT LEAVE BANK TRANSFER APPLICATION I, ________________________________ (name), a current member of the Leave Bank Program, request a benefit in the form of compensated hours ("Benefit") under the ˿Ƶ ("College") Leave Bank Program ("Program") under the facts and for the medical necessity described below: G#: ________________ Employment Date: _____________ Full-time ____ Part-time ____ Date Medical Leave of Absence Began: ________ Estimated Return Date: __________ Date Members Own Paid Leave is Exhausted: _____________ Benefit Requested: _________ (hours; if part-time, attach a copy of your work schedule) Medical reason for this Benefit request (attach supporting documentation and a copy of PCC Request for Leave of Absence Form):_______________________________________________________ I ___ am /___ am not currently receiving workers compensation and/or long term disability insurance benefits. I ___ have / ____ have not been disciplined for any reason related to absences from work under the Classified or Faculty/Academic Professional Agreements within the last 12 months. With respect to Program Benefits, I understand: this application will be reviewed by the Classified and Faculty/Academic Professional/Management Contract Administration Committees in accordance with the terms of the Program and the decision of the Committee is final; subject to hours availability, benefits are available for my medical necessity after I have been on medical leave of absence for at least two consecutive work weeks, and after I have exhausted all my own paid leave, and are limited to 350 hours during and consecutive 365-day period; if I receive a Benefit under the Program and it is later determined that I was ineligible for Program membership or if I am reimbursed for those same hours by a third party, I agree to reimburse the College for the dollar value of the Benefit. The terms of the Program are set out in the Program document, a copy of which is available upon request from the College, and in the event of any discrepancy that document shall control over this form. ________________________________________________________ Signature & Date Return this form to: HR - Benefits DC 3 To be completed by the Classified and Faculty/Academic Professional/Management Contract Administration Committees: To: _______________________________________ Date: ___________________ Your request has been: ____ Approved for ______ hours ____ Denied because:___________________________________________________________________________ by: ___________________________________________ Contract Administration Committee c: Employee Contract Administration Committee Payroll  #$CDim ( j k l E F T U w x _`HIJK()YZغh;CJaJ h;>*h;>*CJaJh;6>*CJ]aJh;0JCJaJh CJaJh;h;6CJ]aJh;CJaJhOt hOt5\ hOt0J?Dk F U x `K)$If$If & Fdd[$\$gd;gd;$a$gd;ekd$$IfZ*0634Zab21h:p;/ =!"#$% $$If!vh#v+:V Z06,5/ 34Z6666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH DA`D Default Paragraph FontRi@R  Table Normal4 l4a (k (No List B^@B A[X Normal (Web)dd[$\$*W@* A[XStrong5\PK!pO[Content_Types].xmlj0Eжr(΢]yl#!MB;.n̨̽\A1&ҫ QWKvUbOX#&1`RT9<l#$>r `С-;c=1g'}ʅ$I1Ê9cY<;*v7'aE\h>=,*8;*4?±ԉoAߤ>82*<")QHxK |]Zz)ӁMSm@\&>!7;ɱʋ3װ1OC5VD Xa?p S4[NS28;Y[꫙,T1|n;+/ʕj\\,E:! t4.T̡ e1 }; [z^pl@ok0e g@GGHPXNT,مde|*YdT\Y䀰+(T7$ow2缂#G֛ʥ?q NK-/M,WgxFV/FQⷶO&ecx\QLW@H!+{[|{!KAi `cm2iU|Y+ ި [[vxrNE3pmR =Y04,!&0+WC܃@oOS2'Sٮ05$ɤ]pm3Ft GɄ-!y"ӉV . `עv,O.%вKasSƭvMz`3{9+e@eՔLy7W_XtlPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-!pO[Content_Types].xmlPK-!֧6 -_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!!Z!theme/theme/theme1.xmlPK-! ѐ'( theme/theme/_rels/themeManager.xml.relsPK]#   km ,5 ) + ::::::::ninHHʪ4^`CJOJQJo(^`CJOJQJo(opp^p`CJOJQJo(@ @ ^@ `CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(PP^P`CJOJQJo(ninHj ;Ot @llyll X@UnknownGTimes New Roman5Symbol3 Arial? Courier New;WingdingsACambria Math"hG'  $24 3HP)?A[X2 ,#PORTLAND COMMUNITY COLLEGE DISTRICTKaren SorensenMelissa Aaberg  Oh+'0 ,8 \ h t'$PORTLAND COMMUNITY COLLEGE DISTRICTKaren Sorensen Normal.dotmMelissa Aaberg3Microsoft Macintosh Word@Ik@up @LG  ՜.+,0  hp|  'PCC  $PORTLAND COMMUNITY COLLEGE DISTRICT Title  !"#$&'()*+,./012347Root Entry FG9Data 1Table WordDocument4SummaryInformation(%DocumentSummaryInformation8-CompObj` F Microsoft Word 97-2004 DocumentNB6WWord.Document.8