DOE OHR 300-001
Last Revised: 01/01/2011
APPLICATION FOR LEAVE OF
Former DOE Form(s): 400, 400a, 400a.1, 400F
DEPARTMENT OF EDUCATION
O fice of Human Resources
Records and Transactions Section, Certificated
P.O. Box 2360 Honolulu, HI 96804
I. EMPLOYEE INFORMATION
Last 4 digits of SSN: _____________________
City: _____________________ State: _______ Zip: ______________
School or Sub-Division Code: _ _ _
Leave Code: _ _ _
Bargaining Unit Code: _ _
II. LEAVE REQUEST (Complete appropriate subsection below.)
Provide relationship to deceased and address if out of state in
Complete and attach Federal Form
Complete Licensed Physician's Statement by completing Section IV
at bottom of this form for Health leave or if Sick leave for more
Attach a copy of your military orders with this form (copy) to
than five (5) consecutive days or submit a signed doctor's note
OHR, Records and Transactions Section, Certificated.
verifying current health condition. Approval for sick leave is
Attach a separate letter justifying political appointment.
subject to the availability of accumulated sick leave.
I hereby request the following type of leave:
Leave with Pay
Leave without Pay
for the calendar period below:
# of working days
1 I thi
1. Is this an extended leave?
t d d l
2. Provide any additional explanation for leave request (attach a separate sheet if necessary):
Employee Signature: _______________________________________________________ Date: _______________________
III. LEAVE APPROVAL
For sick, vacation, and personal leave, Principal/Immediate Supervisor approval required.
For family, military, personnel development, and political leave, both Principal/Immediate Supervisor and PRO/CAS approval required.
Not Approved PRO/CAS Signature:
IV. LICENSED PHYSICIAN'S STATEMENT
(To be completed ONLY for HEALTH LEAVE or if SICK LEAVE is for more than five (5) consecutive work days)
I certify that _________________________________ is under my care for health reasons and is not physically able to perform
his/her normal work duties from _______________________ to ______________________.
Licensed Physician Signature: ________________________________________
Name of Licensed Physician (Print): __________________________________
Type of Practice: ___________________________
Address: __________________________________________________________ Tel#: ____________________________________
Distribution: Leave with Pay (Teachers): 1. Original - School; 2. Copy 1 - Employee; 3. Copy 2 - PRO (if leave exceeds one month) / Leave With Pay (EOs): 1.
Original - School; 2. Copy 1 - Employee / Leave Without Pay and Military Leave With Pay: 1. Original - OHR, Records and Transactions Section, Certificated;
2. Copy 1 - Employee; 3. Copy 2 - School; 4. Copy 3 - PRO; 5. Copy 4 - Payroll Office, Leave Accounting Section
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