Fillable Extended Leave Of Absence Request Form (Page 2 of 2) in pdf

Page 2 of 2

Employee Name:

Request Date:

Except in emergency situations, this form is to be completed PRIOR to the use of extended leave.

Please attach a projected attendance sheet for leave requests longer than one month. Unpaid leave should be

reported immediately to Court Reporting Services by phone or e-mail even if this form is not yet complete.

Administrative Authority Section:

I have reviewed this leave request and have verified the paid leave days requested and available as accurate.

This leave is either approved or denied by me as the administrative authority for court reporters in this circuit.

Approved

Denied*

Chief Judge

or Designee: ____________________________________________________ Date ______________________

Printed

Name:

Title:

*Reason

for denial

Leave Definitions:

Paid Medical Leave - Use of sick leave for an extended period of three or more consecutive days. Paid medical leaves require a

physician's statement indicating the nature and extent of the disability. May also be considered FMLA leave. May be used for the

employee's own illness/injury or for an immediate family member illness.

Unpaid Family Leave - Unpaid leave provided for under the provisions of the Family & Medical Leave Act when taking the leave to

care for a family member or other defined reasons which are not for the employee's own illness/injury. A statement from the family

member's physician should be used/attached. The state's portion of insurance premiums will continue to be paid during this time, if

applicable. The employee will be billed for the employee portion. Limited to 12 weeks from the last day present at work.

Unpaid Medical Leave - After an employee has used all paid leave benefits and unpaid FMLA leave (if applicable), an employee may

be approved for unpaid medical leave (also known as non-occupational leave). During an unpaid medical leave, the employee may apply

for non-occupational disability benefits which are provided by the State Retirement System. To inquire about benefits which may be

available, contact the State Retirement System directly at (217) 785-7444. During approved unpaid medical leave, the state's portion of

the insurance premiums will continue to be paid. Employees will be billed for the employee portion.

Unpaid Personal Leave - Refers to any leave requested for a personal reason which does not fall under the leave provisions of the

Family and Medical Leave Act or unpaid medical leave above. The employee will be required to pay both the state's and the employee's

portion of insurance premiums. Employees may also opt-out of insurance during this time.

Occupational Leave - Refers to any work-related injury or disease. Work-related injuries must be reported to the Office of the

Comptroller immediately, including injuries such as carpal tunnel syndrome. This form must be submitted for paid or unpaid medical

leave of absence if a worker's compensation (temporary total disability) status has not yet been determined.

Return approved leave forms to Court Reporting Services:

Fax (217) 557-0267

OR e-mail SpradD@mail.ioc.state.il.us

Original form should be retained in the Chief Judge's records.

Extended Leave Of Absence Request Form Page 2