SOUTHERN ILLINOIS UNIVERSITY AT EDWARDSVILLE
OFFICE OF HUMAN RESOURCES
EMPLOYEE VACATION/SICK LEAVE REPORTING FORM

This is to certify that upon ( ) Termination ( ) Retirement ( ) Death the following employee or employee’s estate has vacation and/or sick leave balances as indicated below. Please complete this form even if the employee used all vacation and/or sick leave prior to separation. It is IMPORTANT that this information is submitted in a timely manner since unused sick leave affects retirees’ annuity calculations.

ADMINISTRATIVE/PROFESSIONAL STAFF CIVIL SERVICE FACULTY

Employee :

(Last)	(First)	(Middle)
Banner ID:	SSN (last 4 digits):	xxx-xx-
Department:	Date of Termination:
PAYABLE Vacation Balance Due
PAYABLE accrued V250 vacation hours:

(2 yr accrual maximum)

This employee’s PEALEAV vacation leave balances in Banner have been updated. For Banner entry help, please see
http://www.siue.edu/humanresources/benefits/vac_sick_civil.shtml
AIS Budget Purpose:
(If different from current job)	FOR payroll USE ONLY
Payout

Amt: $	Pay period ID:
Processed by:
date:

PAYABLE SICK LEAVE Balance Due
Computation: SK97 sick leave hours earned 1/1/84 through 12/31/97
Total Hrs. =

PAYABLE unused SK97 sick leave hours:
50% of Total Hrs.=	This employee’s PEALEAV sick leave balances in Banner have been updated. For Banner entry help, please see
http://www.siue.edu/humanresources/benefits/vac_sick_civil.shtml
FOR payroll USE ONLY
Payout

Amt: $	Pay period ID:
Processed by:
date:
NONPAYABLE UNUSED SICK LEAVE BALANCES
Unpaid SK97 sick leave hours:
(50% of balance)

SK84 sick leave hours earned prior to 1/1/84:

SICK leave hours earned after 1/1/98:
SN43 sick leave hours:

(Faculty/Ad Staff Only)
TOTAL NONPAYABLE UNUSED

SICK LEAVE HOURS:
This employee’s PEALEAV sick leave balances in Banner have been updated. For Banner entry help, please see
http://www.siue.edu/humanresources/benefits/vac_sick_civil.shtml

Date Human Resources’ Representative	Date Dept. Preparer’s Signature Phone No.

Date Employee’s Supervisor Phone No.
5/7/12 – previous versions are obsolete

Joyree Chura

2012-05-17

Southern Illiniois University Edwardsville