SYRACUSE CITY SCHOOL DISTRICT

SYRACUSE CITY SCHOOL DISTRICT
Office of Talent Management
Sharon L. Contreras, Ph D.
725 Harrison Street• Syracuse, NY 13210
Phone 315•435•4171• Fax 315•435•4163
Superintendent of Schools
REQUEST FOR PAID LEAVE TIME FOR BREAST AND PROSTATE CANCER SCREENING
If you intend on obtaining a breast or prostate cancer screening during your normal work hours you must
complete this form in order to receive leave with pay.
In accordance with New York State Civil Service Law §159-b and §159-c, the Syracuse City School District will
permit employees to take up to four (4) hours of paid leave on an annual basis for the purpose of obtaining
breast and/or prostate cancer screening. These four (4) hours are intended for the screening and reasonable
travel time only.
Please be sure to submit this form to your immediate supervisor at least one (1) week prior to your
appointment to obtain their signature. The supervisor will return this form to you so that you can bring it to
the doctor. When you return to work, please send this completed form to the Payroll Department.
Please also enter your absence into the Smart Find Express Absence System as Excused with Pay. Please enter
the phrase “Health Screening” into the Comment section.
To Be Completed By Employee: Please Print
Name: _______________________________________ Position: ______________________________
School: ______________________________________
Appointment Date: ____________________________ Appointment Time: ______________________
Immediate Supervisor Signature: __________________________________ Date: _________________
To Be Completed by Physician: Please Print
_____________________________________________ was seen on____________________
Employee Name
Date (mm/dd/yyyy)
from _____________am/pm to _____________am/pm by ____________________________________
Time of appt.
Physician Name or Medical Facility
_________________________________________
Business Address
____________________________________
Business Phone Number
_________________________________________
Physician or Authorized Representative’s Signature

Processed by Payroll (please return to Benefits and Leaves Team)