RECORD OF APPLICATION OF DISCRETION EMPLOYEE NAME: _____________________________ EMPLOYEE NUMBER: _____________________________ DATE OF DECISION: _____________________________ REASON FOR CURRENT/MOST RECENT ABSENCE: ________________ TYPE OF ABSENCE: LONG-TERM INTERMITTENT BOTH □ □ □ RELEVANT MITIGATING FACTORS JUSTIFYING APPLICATION OF DISCRETION (Select all that apply) EXTREME LIFE EVENT IMPACT ON EMPLOYEE □ □ ABSENCE HISTORY EXPECTED PERIOD OF RECOVERY □ □ PLEASE DESCRIBE THE IMPACT ON THE EMPLOYEE OF THE THAT LED TO THEIR ABSENCE: PLEASE OUTLINE YOUR RATIONALE FOR APPLICATION OF DISCRETION: DATE THAT PERIOD OF DISCRETION ENDS: ________________ >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> RECORD OF EXTENSTION TO PERIOD OF DISCRETION (if applicable) DATE DECISION TO EXTEND INITIAL PERIOD OF DISCRETION: _______________________________________ PLEASE OUTLINE YOUR RATIONALE FOR EXTENDING INITIAL PERIOD OF DISCRETION DATE THAT EXTENDED PERIOD OF DISCRETION ENDS: _____________________________
RECORD OF APPLICATION OF DISCRETION EMPLOYEE NAME: _____________________________ EMPLOYEE NUMBER: _____________________________ DATE OF DECISION: _____________________________ REASON FOR CURRENT/MOST RECENT ABSENCE: ________________ TYPE OF ABSENCE: □ LONG-TERM □ INTERMITTENT □ BOTH RELEVANT MITIGATING FACTORS JUSTIFYING APPLICATION OF DISCRETION (Select all that apply) □ EXTREME LIFE EVENT □ IMPACT ON EMPLOYEE □ ABSENCE HISTORY □ EXPECTED PERIOD OF RECOVERY PLEASE DESCRIBE THE IMPACT ON THE EMPLOYEE OF THE THAT LED TO THEIR ABSENCE: PLEASE OUTLINE YOUR RATIONALE FOR APPLICATION OF DISCRETION: DATE THAT PERIOD OF DISCRETION ENDS: ________________ >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> RECORD OF EXTENSTION TO PERIOD OF DISCRETION (if applicable) DATE DECISION TO EXTEND INITIAL PERIOD OF DISCRETION: _______________________________________ PLEASE OUTLINE YOUR RATIONALE FOR EXTENDING INITIAL PERIOD OF DISCRETION DATE THAT EXTENDED PERIOD OF DISCRETION ENDS: _____________________________
SAAW_Application_of_managers_decision_(1).docx