Clark County School District
EMPLOYEE ABSENCE REQUEST/AUTHORIZATION
SOCIAL SECURITY NO.
REASON FOR ABSENCE
Please use code numbers listed below.
SCHOOL NAME or WORK LOCATION
Personal illness #
This report covers absence on the following dates:
Illness in immediate family #
4. * Jury duty
5. * Subpoena as witness
6. * Personal leave
7. * See Below
8. * See Below
9. * Military
Please place a date, reason code, and hours/days
10. * Non-paid - with or without leave
# Family Medical Leave Notice: Absences
11. * Paid vacation
in each square for each absence:
may affect eligibility and may be deducted
A maximum of 7 days absence may be reported on each form.
from FML entitlement. Read the full notice
14. * Time out (year-round only)
16. * Compensatory (Comp) time used
on reverse side of this form.
17. * Universal/Flexible day
District business/activity without students
Were you absent on a day prior to or following a holiday?
______ / ______
(recruitment, state meetings, conferences, etc.)
Indicate holiday __________________________________________
(no substitute teacher required)
7. *School business / activity with students (athletic trip, field trip)
______ / ______ Did you notify your supervisor that you were to be absent?
Name of activity: ______________________ (requires substitute teacher)
______ / ______ Did you see a doctor if reason was for personal (01) or
8. * Authorized absence / activity without students
family (02) illness?
(professional development, sport clinics, SPTA, etc.)
Name of activity: _______________________________________________
(requires substitute teacher/preapproved budget coding)
SIGNATURE OF EMPLOYEE
Authorizing unit __________ Grant/Ph___________/______ (if applicable)
Sub Authorized by: ____________________________________________
SIGNATURE OF SUPERVISING ADMINISTRATOR
*ApprovAl required prior to pending
Absence/vAcAtion/compensAtory time, etc.
Original copy to be retained by supervising administrator
2nd copy to the employee with disposition
Family Medical Leave (FML) Notice
All absences taken for one of the following “qualifying events” will run concurrently with and be
deducted from your annual FML entitlement of 12 weeks:
For the birth, care, or placement of a child for adoption or foster care;
To care for an immediate family member (spouse, child, or parent) with a serious
health condition; or
To take medical leave when you, the employee, are unable to work because of a
serious health condition.
Employees are required to have worked 1250 hours during the preceding 12 months and have worked
for the CCSD for at least 12 months to be eligible for FML. All absences, whether for a qualifying
event or otherwise, will be deducted from calculations of the total hours worked.
Should you continue to be absent for a qualifying event beyond your 12 week annual entitlement
and/or exhaust your accumulated eligible leave, you will be required to apply for an appropriate
leave of absence.
CCSD Regulation 4359 provides additional details for FML. You are encouraged to contact the
Human Resources Division for further information if needed.