Fillable Leave Request Form - City Colleges Of Chicago printable pdf download

LEAVE REQUEST FORM

Employee Status:

Full-Time

Part-Time

Union Status:

 NBF

 Local 1708  Local 1600  Local 3506  Local 1220  Local 399  Local 73  IEA-NEA

 Local 7

EMPLOYEE INFORMATION:

Name:

_______________________________________________________

Employee ID: ____________________________________________________

College/District Office: _____________________________________________

Department: _____________________________________________________

Position Title: ____________________________________________________

Home Telephone No.: _____________________________________________

Job Family: ______________________________________________________

Work Telephone No.: ______________________________________________

LEAVE INFORMATION:

Type of Leave:

Illness

Medical

Family and Medical Leave (FMLA)

Maternity (Local 1600)

The birth and or care of a child

Parental (Local 1708)

Maternity/Parental (NBF)

Peace Corp

Placement of a child with the employee for adoption or foster care

Military Leave

Professional

To care for a spouse, child, or parent with a serious health condition

Serious health condition of the employee that makes it impossible

Personal

Special

for him/her to perform the functions of his/her job.

Workers’ Compensation

Summer

Other __________________________________________

Requested Leave:

Paid

Unpaid

Leave Dates:

Intermittent

________/________/________ to ________/________/________

(month)

(day)

(year)

(month)

(day)

(year)

If your FMLA leave is for your own serious health condition or for the serious health condition of a family member that resides with you, your FMLA leave will

be paid first using your sick time, next using any personal or floating holidays, and lastly using your vacation time.

FMLA leave for all other reasons will be paid using any personal or floating holidays, and then using your vacation time. Sick time cannot be used to cover

these types of leaves.

Instructions:

Please submit this form to your HR Manager or the Benefits Department Leave Management Team. You MUST submit all medical documentation

from your health care provider to the Benefits Department Leave Management Team.

Signature of Employee

Date

FOR ADMINISTRATIVE USE ONLY: Approved by District Office of Human Resources

Yes

Benefits Department Leave Administrator

Date

College President/Vice Chancellor

Date