Form DA325 "Shared Leave Request Form" - Kansas

What Is Form DA325?

This is a legal form that was released by the Kansas Department of Administration - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2014;
  • The latest edition provided by the Kansas Department of Administration;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DA325 by clicking the link below or browse more documents and templates provided by the Kansas Department of Administration.

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Download Form DA325 "Shared Leave Request Form" - Kansas

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COMMITTEE
DA 325 (Revised 10/14)
STATE OF KANSAS
SHARED LEAVE PROGRAM
Shared Leave Request Form
When completing forms please write legibly and be clear and thorough with explanations.
Employee Name __________________________
Employee ID#
PART I – To be completed by employee or employee’s representative
Name ______________________________________________
Employee ID #
Home Address _______________________________________
SSN
(City)
(State)
(Zip)
Home Telephone _____________________________________
Work Telephone
Agency Name _______________________________________
Department ID#
Date of Employment __________________________________
Request is for: Self _____________
Family Member
Name of Family Member and explanation of relationship (please include age if child):
Date illness/injury began: _______________________
Anticipated duration:
Estimate of number of hours requested: ________
Date all paid leave will be/was exhausted
Shared leave will only be granted for serious, extreme, or life-threatening illnesses, injuries, impairments or physical or
mental conditions which have caused, or are likely to cause, the employee to take leave without pay or terminate
employment. Shared leave will not be granted for common or minor illnesses, injuries, impairments or physical or mental
conditions. To be eligible for consideration, an employee must not have a history of leave abuse within the last year.
Describe and provide any necessary information that would help in concluding that the illness, injury, impairment or
physical condition is serious, extreme or life-threatening:
Are you currently receiving Worker’s Compensation? ____________________
Are you currently receiving Long-Term Disability Payments? _____________
Have you applied for Worker’s Compensation? _________________________
Date Applied:
Have you applied for Long-Term Disability Payments? ___________________
Date Applied:
I certify that I understand, agree to and meet the requirement and conditions of the shared leave program as authorized in
K.A.R. 1-9-23. I authorize the appointing authority to obtain any necessary information regarding my request for shared
leave and to share that information with the Shared Leave Committee. I understand that denial of this application is not
subject to appeal to the Civil Service Board. I declare under penalty of perjury that the foregoing is true and correct.
Executed on date below.
Employee Signature
Date
COMMITTEE
DA 325 (Revised 10/14)
STATE OF KANSAS
SHARED LEAVE PROGRAM
Shared Leave Request Form
When completing forms please write legibly and be clear and thorough with explanations.
Employee Name __________________________
Employee ID#
PART I – To be completed by employee or employee’s representative
Name ______________________________________________
Employee ID #
Home Address _______________________________________
SSN
(City)
(State)
(Zip)
Home Telephone _____________________________________
Work Telephone
Agency Name _______________________________________
Department ID#
Date of Employment __________________________________
Request is for: Self _____________
Family Member
Name of Family Member and explanation of relationship (please include age if child):
Date illness/injury began: _______________________
Anticipated duration:
Estimate of number of hours requested: ________
Date all paid leave will be/was exhausted
Shared leave will only be granted for serious, extreme, or life-threatening illnesses, injuries, impairments or physical or
mental conditions which have caused, or are likely to cause, the employee to take leave without pay or terminate
employment. Shared leave will not be granted for common or minor illnesses, injuries, impairments or physical or mental
conditions. To be eligible for consideration, an employee must not have a history of leave abuse within the last year.
Describe and provide any necessary information that would help in concluding that the illness, injury, impairment or
physical condition is serious, extreme or life-threatening:
Are you currently receiving Worker’s Compensation? ____________________
Are you currently receiving Long-Term Disability Payments? _____________
Have you applied for Worker’s Compensation? _________________________
Date Applied:
Have you applied for Long-Term Disability Payments? ___________________
Date Applied:
I certify that I understand, agree to and meet the requirement and conditions of the shared leave program as authorized in
K.A.R. 1-9-23. I authorize the appointing authority to obtain any necessary information regarding my request for shared
leave and to share that information with the Shared Leave Committee. I understand that denial of this application is not
subject to appeal to the Civil Service Board. I declare under penalty of perjury that the foregoing is true and correct.
Executed on date below.
Employee Signature
Date
COMMITTEE
DA 325 (Revised 10/14)
STATE OF KANSAS
SHARED LEAVE PROGRAM
Shared Leave Request Form
When completing forms please write legibly and be clear and thorough with explanations.
Employee Name __________________________
Employee ID#
PART II –
Licensed Health Care provider Statement.
IF THIS REQUEST IS FOR THE CARE OF A FAMILY MEMBER PLEASE INDICATE THE ROLE THEY WILL HAVE IN
THE CARE.
Patient’s Name _________________________________________________________________________________________
Date first consulted for this condition ________________________________________________________________________
Describe the nature of the illness, injury, impairment or physical or mental condition (please attach documentation):
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Describe the diagnosis of the illness, injury, impairment or physical or mental condition (please attach documentation):
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Describe the treatment and prognosis of the illness, injury, impairment or physical or mental condition (please attach documentation):
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Anticipated duration the patient will be unable to work due to the condition: From
Through
Dates of hospitalization (if applicable): From
Through
Date of Surgery (if applicable):
Physician Name _____________________________________________
Telephone Number
Address _______________________________________________________________________________________________
______________________________________________________________________________________________________
City
State
Zip
Licensed Health Care provider Signature __________________________________
Date
COMMITTEE
DA 325 (Revised 10/14)
STATE OF KANSAS
SHARED LEAVE PROGRAM
Shared Leave Request Form
When completing forms please write legibly and be clear and thorough with explanations.
Employee Name __________________________
Employee ID#
PART III – To be completed by the Agency human Resource Office of Umbrella Agencies.
________
The employee has used, or will use all forms of paid leave including vacation leave, sick leave and
compensatory time credits as of
.
The employee’s last day physically at work was
________
.
________
The employee has six months of continuous service.
________
The Relationship meets the requirements set forth in K.A.R. 1-9-23 if the request is for the care of a family
member. (Mark N/A if the request is for the employee.)
We certify that the employee meets all the initial eligibility requirements above and has maintained a satisfactory
attendance and/or leave record within the past year.
Appointing Authority or Designee
Date
If an employee does not meet all the initial eligibility requirements or has not maintained a satisfactory attendance record, take no
further action. File this request and notify the employee.
ATTN: Shared Leave Committee –c/o Jolene Flowers
Please forward completed form to
Office of Personnel Services, 900
SW Jackson, Room 401-N, Topeka, KS 66612 or fax to (785) 296-7712.
Please submit the name of person to be contacted with the committee decision. This will be done by e-mail which will also be
your official confirmation for records.
E-mail reply to:
PART IV – To be completed by Shared Leave Committee.
We have reviewed the request and make the following recommendation:
Approve
Deny – Does not rise to the level of being serious, extreme or life-threatening
Return for additional information/clarification What:
Shared Leave Committee Representative _____________________________________________
Date
PART V – To be completed by the appointing authority
I hereby (please circle one)
APPROVE
DENY
the use of shared leave for
hours through
Appointing Authority Signature
Date
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