Fillable Request To Receive Catastrophic (Cat) Leave Template printable pdf download

Nevada System of Higher Education

BUSINESS CENTER NORTH

REQUEST TO RECEIVE CATASTROPHIC (CAT) LEAVE

Section 1 -To be completed by the employee or designated representative (please print or type)

Name: ____________________________________

Employee ID# _______________________________

Job Title: _________________________________

Department: _________________________________

Campus:  UNR  DRI

 GBC  TMCC  WNC  Sys Admin

I am requesting catastrophic leave donations for (check one):

My own medical condition requiring a "lengthy convalescence" (per NAC 284.575)

My own medical condition which is "life threatening" (per NAC 284.575)

A serious illness or accident which is "life threatening" or which will require a "lengthy convalescence" in my immediate

family (per NRS 284.362(2), NAC 284.5235, and NAC 284.558)

The death of an immediate family member (per NRS 284.362(3) and NAC 284.5235 and NAC 284.558)

If the request for catastrophic leave is due to a catastrophe in your immediate family, please indicate the name and your relationship to

the family member.

Name_______________________________________________ Relationship______________________________________

I will need to use CAT leave beginning ______________ and ending on _______________for a total of ____________ hours.

I have applied for Family Medical Leave (FMLA):  Yes

 No

I authorize release of my name to the campus leave administrator to solicit CAT leave donations on my behalf. Solicitation may

include but not limited to campus email, website and organization announcements.  Yes  No

Employee’s Signature: __________________________________________________

Date: ______________

Submit Physician’s Certification for Catastrophic Leave Request (Form PAY-23C) via fax to BCN Benefits at 775-784-4221.

The approval or denial of the request is at the discretion of the appointing authority, who has the prerogative to not approve a

request based upon the availability of funds on grant and soft money accounts or the employee’s past leave history in accordance with

NAC 284.576. Please review CAT leave policy for further information (available from your leave keeper or BCN Benefits office).

An employee "aggrieved" by any decision of an appointing authority may appeal the decision by filing a written notice of appeal

(Form PAY-23B) with the Committee on Catastrophic Leave within 10 days after the date of the decision.

Section 2 – To be completed by Department Leave Record Keeper, Supervisor and Appointing Authority

Exhausted Approved Not eligible

Department Leave Keeper: date employee exhausts all sick/annual/comp time accrued __________ FMLA status ______________

Print Name: _____________________________________________Signature_________________________Date_______________

Supervisor Name: ________________________________________ Signature: _______________________ Date_______________

 Yes

 No

Appointing Authority: leave request recommended for approval

Appointing Authority Name: ________________________________Signature: _______________________ Date: ______________

RETURN A COMPLETED FORM TO BCN BENEFITS, MS 0240

Once BCN Benefits staff obtains the information from the department and employee’s physician, employee will be notified whether

leave will be designated as Catastropic Leave. If you have any questions, please do not hesitate to contact BCN Benefits office by

phone (775) 784-6112.

CAT-1 Form

BCN Benefits

Request To Receive Catastrophic (Cat) Leave Template

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