APPENDIX D

   VILLAGE OF ORLAND BILLS SICK LEAVE FORM

Date:   

Employee:   

Department:   

Sick Leave Dates Used:   

Reason for Sick Leaves:*   

Total Number of Sick Days Available:   

Total Number of Sick Days Used:   

Total Number of Sick Days Remaining:   

Employee Signature:    

Supervisor Approval:    

Supervisor Denial:   

* Employee absent from work for more than three (3) consecutive work days must provide a physician's statement indicating the nature of the illness and incapacity for duty.

Copies:   Finance

      Department

      Employee

(Ord. 89-09, passed 4-12-89)