Personnel Leave of Absence Form

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PERSONNEL LEAVE OF ABSENCE FORM
(to be completed by Employee)
Note: Please refer to contract provisions regarding leave of absence. Initial approval may be given
verbally, but will be confirmed in writing.
Name: ____________________________________ SS#:________________________
School/Department: _______________________
Position: ____________________
Type of Leave Requested: □ FAMILY
□ OTHER
□ BOTH
FAMILY LEAVE INFORMATION
All employees are entitled to 12 weeks of unpaid leave in a 12-month period. Employee health benefits
will be maintained during this unpaid leave. Employee is responsible for paying the Chapter 78 portion of
benefits premium while out on leave for benefits.
□ Birth/Adoption/Foster Care of Child
Reason for Leave:
□ Family Member Health Condition*
□ Employee Health Condition*
Leave to start: ____________________
Leave to end: ______________________
Remarks: _______________________________________________________________
Have you taken a FMLA family or medical leave in the past 12 months? □ Yes □ No
OTHER LEAVE INFORMATION
Other Leave Type: □ Maternity (no pay, no benefits unless employee pays premiums)
□ Medical* (no pay, no benefits unless employee pays premiums)
□ Personal (no pay, no benefits unless employee pays premiums)
Leave to start: ____________________
Leave to end: ______________________
□ Yes
□ No
Are you requesting an extension of an existing leave?**
If Yes, indicate type of prior leave: _________________________________________
Reason for leave/Remarks: ________________________________________________
*Attach appropriate documentation from physician
** Please be advised that additional (over 1) extensions will be approved at the Board’s discretion.
SICK DAYS/VACATION DAYS/PERSONAL DAYS
If you intend on using Sick Days, Vacation Days (12 month employees only) and/or
Personal Days prior to the requested leave, please indicate the dates below:
_____ Sick Days
Dates: __________________________
_____ Personal Days
Dates: __________________________
_____ Vacation Days
Dates: __________________________
Employee’s Signature: ___________________________
Date: _____________
TO BE COMPLETED BY CENTRAL OFFICE ADMINISTRATION
Administrator’s Approval: ________________________________
Date: __________
Personnel Administrator’s Approval: ________________________ Date: __________
Board Agenda Date: ____________________ Replacement Needed? □ Yes
□ No
MAIL ORIGINAL FORM TO DAWN IN PERSONNEL AND A COPY TO YOUR SUPERVISOR.
PERSONNEL LEAVE OF ABSENCE FORM
(to be completed by Employee)
Note: Please refer to contract provisions regarding leave of absence. Initial approval may be given
verbally, but will be confirmed in writing.
Name: ____________________________________ SS#:________________________
School/Department: _______________________
Position: ____________________
Type of Leave Requested: □ FAMILY
□ OTHER
□ BOTH
FAMILY LEAVE INFORMATION
All employees are entitled to 12 weeks of unpaid leave in a 12-month period. Employee health benefits
will be maintained during this unpaid leave. Employee is responsible for paying the Chapter 78 portion of
benefits premium while out on leave for benefits.
□ Birth/Adoption/Foster Care of Child
Reason for Leave:
□ Family Member Health Condition*
□ Employee Health Condition*
Leave to start: ____________________
Leave to end: ______________________
Remarks: _______________________________________________________________
Have you taken a FMLA family or medical leave in the past 12 months? □ Yes □ No
OTHER LEAVE INFORMATION
Other Leave Type: □ Maternity (no pay, no benefits unless employee pays premiums)
□ Medical* (no pay, no benefits unless employee pays premiums)
□ Personal (no pay, no benefits unless employee pays premiums)
Leave to start: ____________________
Leave to end: ______________________
□ Yes
□ No
Are you requesting an extension of an existing leave?**
If Yes, indicate type of prior leave: _________________________________________
Reason for leave/Remarks: ________________________________________________
*Attach appropriate documentation from physician
** Please be advised that additional (over 1) extensions will be approved at the Board’s discretion.
SICK DAYS/VACATION DAYS/PERSONAL DAYS
If you intend on using Sick Days, Vacation Days (12 month employees only) and/or
Personal Days prior to the requested leave, please indicate the dates below:
_____ Sick Days
Dates: __________________________
_____ Personal Days
Dates: __________________________
_____ Vacation Days
Dates: __________________________
Employee’s Signature: ___________________________
Date: _____________
TO BE COMPLETED BY CENTRAL OFFICE ADMINISTRATION
Administrator’s Approval: ________________________________
Date: __________
Personnel Administrator’s Approval: ________________________ Date: __________
Board Agenda Date: ____________________ Replacement Needed? □ Yes
□ No
MAIL ORIGINAL FORM TO DAWN IN PERSONNEL AND A COPY TO YOUR SUPERVISOR.

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