Catastrophic Sick Bank Request from Humble Independent School District

Catastrophic Sick Bank Request

Assigned To: Public User

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Please answer the questions below.

Catastrophic Sick Bank Request

Request for additional paid leave days from the Castastrophic Sick Bank

First Name:	Last Name	Employee ID
First required	Last required	Emp ID required
Street Address	Address Line 2	City
Address required		City required
Zip Code	Home Phone	Cell Phone
Zip required		Cell Phone required

This request is for

Personal illness or injury

Caring for an immediate family member

Medical reason why you are requesting CSB days:

Are you a full member of the CSB?

Yes
No

Does this illness/injury qualify you for Workers Comp or Assault Leave?

Yes
No

A signed, dated physician’s statement must be sent with this request. The statement must confirm the catastrophic(1) nature of the illness/injury and certify either the employee’s inability to perform assigned work duties or the family member’s need for the employee’s care. Send the medical certification via inner-office mail, fax or by uploading the document using the link below:

Cecilia Alas, HR Analyst
Phone: 281-641-8224
Fax: 281-641-1057

(1)“Catastrophic” is defined as an injury or illness of a devastating and disastrous nature, most likely involving extended hospitalization and/or an inability to work, or perform other regular daily activities, for an extended time.

Medical Certification Upload

Type your name and click to Digitally Sign (You must click on Submit after signing the form)

By typing in your name (your “eSignature”), you accept and consent to be legally bound by this document’s statements, terms and conditions as if this document was signed by you in writing with pen on paper. You agree that no third party or other means of verification is necessary to validate your eSignature and that the lack of such third party or other means of verification will not in any way affect the enforceability of this document.

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History

Step: Someone fills out the form
Sent To: Public User, On: 12/21/2025 7:58:12 PM Central Standard Time

Humble Independent School District - Catastrophic Sick Bank Request