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Form #0112 (02/11)

General Order 1-012 states it is the policy of the Knox County Sheriff’s Office that any employee who has a sick leave absence of 3 days or more shall furnish his/her supervisor with a doctor’s excuse indicating the type of injury or illness (reason for sick leave), and the fact that the doctor certifies that the employee is unable to perform any light duty of any type for KCSO. Failure to provide the sick leave documentation as required will render the employee absence sick leave without pay without further action of his/her supervisor.

Employee’s Signature / ID #

Date

Supervisor’s Signature / ID #

Date

Form #0112 (02/11)