Abraham Baldwin Agricultural College

Shared Leave

Page 1 to be completed by employee:

Statement from Abraham Baldwin Agricultural College employee to the licensed physician:

I am applying for leave through the Abraham Baldwin Agricultural College (ABAC) shared leave program due to my illness or injury.  ABAC’s shared leave program allows employees affected by emergency or life-threatening medical conditions (defined as conditions involving a serious, extreme, or life-threatening illness, injury, impairment or condition) and who also meet other specified criteria, to receive leave donated by other employees.  A committee of ABAC employees will review my application to determine if my request meets the criteria for approval.  Your certification of my medical condition is crucial in making that determination.  Your response to each question on the attached page will be greatly appreciated.  I authorize any licensed medical practitioner who examines me to release any information or facts concerning my condition to:  Abraham Baldwin Agricultural College, Office of Human Resources; the Shared Leave Certification Committee; and to other appropriate ABAC officials.

For the purposes of this program, “life-threatening or emergency medical condition” means a health condition involving a serious, extreme, or life-threatening illness, injury, impairment, or condition that is likely to require my absence from duty for a period of time longer than the amount of sick leave and annual leave available to me, and the health condition is such that it is not medically appropriate for me to delay the absence in order to accrue additional sick or annual leave prior to the absence.  The absence may be continuous, as in hospitalization following surgery or an accident, or the absence may be intermittent, as in periodic absences for chemotherapy or other procedures.

I understand any medical information forwarded to the Shared Leave Committee will remain confidential and will not be shared with other employees in Human Resources, my department, or elsewhere within the College. 

___________________________________________________________          _______________________________________

Name of employee         (please print)                                         Social Security Number

___________________________________________________________          _______________________________________

Signature of employee                                                                Date

(Or the printed name and signature of the person having documented

power of attorney for the named employee.  Attach documentation of

power of attorney.)

 Revised April 2004