Employee Absence Request/authorization Form Ccf-101 - Clark County School District
Download a blank fillable Employee Absence Request/authorization Form Ccf-101 - Clark County School District in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Employee Absence Request/authorization Form Ccf-101 - Clark County School District with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Clark County School District
9998-500101
CCF-101
Rev. 09/04
EMPLOYEE ABSENCE REQUEST/AUTHORIZATION
Please Print
LAST NAME
FIRST NAME
M.I.
SOCIAL SECURITY NO.
REASON FOR ABSENCE
Please use code numbers listed below.
LOC. CODE
SCHOOL NAME or WORK LOCATION
JOB #
1.
Personal illness #
This report covers absence on the following dates:
MONTH/S
2.
Illness in immediate family #
SCHOOL POLICE/SUPPORT
3.
Bereavement
ADMIN/LICENSED
DATE:
PERSONNEL ABSENCE
PERSONNEL ABSENCE
4. * Jury duty
REASON:
5. * Subpoena as witness
CODE:
6. * Personal leave
7. * See Below
DAYS/
Total DAYS
Total HOURS
Total HOURS
8. * See Below
HOURS:
(Admin. Comp.)
9. * Military
Sun.
Mon.
Tues. Wed.
Thur.
Fri.
Sat.
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
13.
Worker’s Compensation
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.
YES
NO
17. * Universal/Flexible day
28.
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
DATE
Authorizing unit __________ Grant/Ph___________/______ (if applicable)
Sub Authorized by: ____________________________________________
_________________________________________________________________
SIGNATURE OF SUPERVISING ADMINISTRATOR
DATE
*ApprovAl required prior to pending
Absence/vAcAtion/compensAtory time, etc.
DISTRIBUTION:
Original copy to be retained by supervising administrator
030
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.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business