Leave Of Absence Form - Wellesley Public Schools (Page 2 of 3) in pdf

Leave Of Absence Form - Wellesley Public Schools Page 2

I wish to use the following accrued time off benefits during my leave as allowed by school policy:

Sick Time

Personal Time

Vacation Time

Not Applicable

During my leave I will:

Continue my:

medical

dental

basic life insurance

supplemental life insurance

disability insurance

I understand that I am responsible for any premium payments, either through payroll deduction or

direct billing in order to continue my benefits as checked above.

I understand that I will be required to furnish a return to work doctor’s note prior to returning to work

(medical leave of absence only). I understand that my position or an equivalent one, will be held for

leaves granted to me under my bargaining unit contract, FMLA or the Massachusetts Maternity Leave

Law, if I return by the approved leave end date.

I certify all information that I have or will provide in connection with this leave request is true and

accurate. I understand that my request for leave of absence will be considered approved, after I receive a

copy of this formed signed by the Superintendent of Schools.

Employee Signature

Date Signed

Supervisor’s Signature

Date Signed

Principal’s Signature

Date Signed

Supervisor/Principal Comments:

MANAGEMENT ACTION

Approved

From ___/___/___ to ___/___/___ If extension, previous leave ___/___/___ to

___/___/___ Approval is conditional based upon receipt of the certification form.

Absence is expect to be:

Continuous

Intermittent

Reduced Schedule

Leave will be counted against FMLA

Yes

FMLA time period

Leave will be counted toward MMLA

Yes

MMLA time period

Leave Of Absence Form - Wellesley Public Schools Page 2