Romulus Community Schools Request For Leave Of Absence printable pdf download

High Expectations, High Achievement:

Romulus Community Schools

Everyone, Everyday.

Human Resource Office

Request for Leave of Absence – Form A

Whenever possible, you must notify the RCS Human Resource Office, at least thirty (30) days prior to the commencement of your leave of absence.

Extended leaves are those expected to last more than five (5) working days. Union contract and applicable Federal and State law govern these leaves.

Your eligibility for leave will be determined after receiving this form and all relevant supporting documentation. Your leave will not be processed

until complete. You will be notified of your leave status as soon as possible.

Your Information – Please Print Legibly!

Today’s Date:

__________________________________________________________

____/____/____

Name:

____________________________________________________________________________________________

Address

Street

________________________________________________

(_____) __________-__________

Home Phone #:

City, State Zip

(_____) __________-__________

Work Location: __________________________________________________

Work Phone #:

Select the Type of Leave You Are Requesting

Select only one type of leave. These leaves require information that is requested below or documentation that must be attached to this form. All Step 3 FMLA forms

are available in the Human Resource Office. All leaves require the forms indicated below.

Type of Leave

Required Documentation

STEP 1

STEP 3

STEP 2

Select ONE Type of Leave

Add’t Documentation Required

Complete and Return These Forms to HR for Step 3

(HR provides upon completion of Step 2)

(available on website)

Medical Leave – Continuous for

Request for Leave of Absence – FORM A &



FMLA Form WH-380-F Care of Family Member

Illness in the Immediate Family

Employee Permission – FORM B

Request for Leave of Absence – FORM A &



Medical Leave – Continuous for Self

FMLA Form WH-380-E Employee Illness

Employee Permission – FORM B

Request for Leave of Absence – FORM A &

FMLA Form WH-380-E Employee Illness

Employee Permission – FORM B

Medical Leave – Intermittent for Self



or Immediate Family

Request for Leave of Absence – FORM A &

FMLA Form WH-380-F Care of Family Member

Employee Permission – FORM B

Military Family Leave – Injury or

Request for Leave of Absence – FORM A &

FMLA Form WH-385 Injury or Illness of Covered



Illness

Employee Permission – FORM B

Service Member

Military Family Leave – Qualifying

FMLA Form WH-384 Qualifying Exigency –



Request for Leave of Absence – FORM A

Exigency

Military



Military Service Leave

Attach military orders or commander’s letter.

n/a



Parental Leave – Non-Birth Only

Attach legal documentation of adoption or foster care placement.

n/a

Request for Leave of Absence – FORM A &



Parental Leave - Birth of Child

FMLA Form WH-380-E Employee Illness

Employee Permission – FORM B



Personal Leave of Absence

Request for Personal Leave – Statement Page

n/a

Designate the Period of Leave Requested

Requested Leave Start Date:

_______________________

Expected Leave End Date: ________________________

Regarding the Use of Available Paid Leave

**OFFICE USE ONLY **

Please refer to applicable Collective Bargaining Agreement and/or

Human Resource Office regarding the use of available paid leave. For

 Approved – Comments: ____________________________________

approved FMLA Leave the district will exhaust all your available leave

balances. Your available leave will be used in this order: sick leave,

___________________________________________________________

personal days, and vacation leave. After these accruals are exhausted,

the remainder of your leave will be unpaid. Employees on a leave of

 Denied – Comments: ______________________________________

absence beyond FMLA Allotment including applicable unpaid leaves

may continue current insurance programs by payment of 100% of the

premium through COBRA Rights.

___________________________________________________________

Employee Signature

Return indicated STEP 2 forms to the Human Resource Office. You

will be given the appropriate STEP 3 documentation in HR.

______________________________________________ ___________

__________________________________________________________

Gary Banas, Director of Human Resources

Date

Employee Signature

Date

Request for Leave of Absence - FORM A

Updated 6-12-2012

Romulus Community Schools Request For Leave Of Absence

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