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Commonwealth of Massachusetts
Human Resource Division
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Extended Illness Leave Bank Enrollment

Effective Membership Date:

This section must be completed by all applicants

Select the appropriate box and complete the employee section before submitting:
Application Type
Employee e-mail required to receive application updates

Applicant must donate at least one sick, vacation, or personal day.
Minimum # of hours I need to donate:

Number of hours I wish to donate:

Short-term and long-term disability plans and other sources of compensation will affect a member's eligibility to withdraw time from the Extended Illness Leave Bank. (Please see your Extended Illness Leave Bank Coordinator if you have any questions concerning how such benefit programs interact with Extended Illness Leave Bank).

Extended Illness Leave Bank Website

This section must be completed by the employee’s supervisor no later than fourteen (14) days after the close of the open enrollment period. Please visit the Extended Illness Leave Bank Website for specific dates.

Definition of Acceptable Attendance Record:

You are being asked to certify that each applicant for membership has an acceptable attendance record. This certification will mean that you have reviewed the total sick leave usage of each applicant, have determined that all absences due to sickness were sufficiently documented where appropriate, and that this documentation will be open to inspection at HRD’s request.

Some examples of cases that would require close review are: a high total sick leave usage not otherwise protected by the Family and Medical Leave Act or a reasonable accommodation; a pattern of absences before or after holidays or on Mondays and Fridays, regardless of whether or not total usage is high; or a history of written or oral warnings for sick leave misuse or abuse.

This section must be completed by the coordinator.