Leave Of Absence Form - Wellesley Public Schools Page 3

Denied

Provider

Certification of need for absence by a health care provider is required at or prior to

commencement of the leave.

Certification by a health care provider regarding continuing need for absence will be

required as requested.

A health care provider’s fitness-for-duty certification and release is required upon return to

active employment.

Evidence of adoption or foster care placement is required.

Substitute has been requested/position has been posted:

Yes

Employee wishes to utilize (must be approved):

Sick Time

Personal Time

Vacation Time

Estimated unpaid date:

Human Resources Signature

Date

Superintendent’s Signature

Date

Copies: Employee

Supervisor

Principal

Personnel file

Payroll Coordinator

Director of Budgets and Finance

Superintendent’s Office

0 votes

Parent category: Business