Department Of Children And Families Office Of Human Resources Leave Of Absence Forms
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1
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3Department of Children and Families
Office of Human Resources
Leave of Absence Package
All types of leave require supporting documentation or a narrative describing the reason for the leave. The
Leave of Absence Request Form will not be considered without the required documentation/information as
described in the Departmental Leave Policy. Failure to complete this application in its entirety may result in
the denial of your leave.
Employees on leave must notify the Office of Human Resources, and their supervisor, at least two (2) weeks
prior to the end of their leave whether they are going to return to work (with necessary documentation),
resign in good standing, request an extension, or file for retirement. Employees who fail to return on their
designated date without notifying the Office of Human Resources and their supervisor of their intentions, may
be terminated for abandonment of position after five (5) days.
Employees are responsible for maintaining their Health Benefit and/or Dental co-payments while on leave
without pay. If an employee fails to pay the necessary co-payments, his/her benefits will be terminated. An
employee whose benefits are terminated is eligible for COBRA benefits. When the employee returns to
work, the benefits can be reinstated by completing Health Benefits and Dental Applications and forwarding
them to the Office of Human Resources Leave Unit (Cost Code #941, P.O. Box 717) by the second day of
the employee’s return.
Required Supporting Documentation by Leave Type
Leave Type
Required Documentation
Medical Leave
WH-380-E Completed by the Employee and Employee’s
(For Eligible Employee)
Medical Provider
Family Medical Leave
WH-380-F Completed by Employee and Family Member’s
(Care for Eligible Family Member)
Medical Provider
Leave for Child Bonding
Birth certificate, pregnancy disability medical documentation or
legal documents placing the child (adoption or foster care)
Military Leave
Military Orders
Convention Leave
Document from union identifying applicant as a delegate or
attendance confirmation documents
Emergency Civilian Duty
Letter from American Red Cross requesting applicant’s
assistance, or Gubernatorial or Presidential Order (as
applicable)
Leave to Appear as a Witness
Summons
School Volunteer
Letter from school administrator identifying the activity and
that it is Board of Education approved - A copy of the ECATS
Approved Leave Request for travel time.
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