Personnel Leave Of Absence Form
Download a blank fillable Personnel Leave Of Absence Form 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 Personnel Leave Of Absence Form 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
1PERSONNEL LEAVE OF ABSENCE FORM
(to be completed by Employee)
Note: Please refer to contract provisions regarding leave of absence. Initial approval may be given
verbally, but will be confirmed in writing.
Name: ____________________________________ SS#:________________________
School/Department: _______________________
Position: ____________________
Type of Leave Requested: □ FAMILY
□ OTHER
□ BOTH
FAMILY LEAVE INFORMATION
All employees are entitled to 12 weeks of unpaid leave in a 12-month period. Employee health benefits
will be maintained during this unpaid leave. Employee is responsible for paying the Chapter 78 portion of
benefits premium while out on leave for benefits.
□ Birth/Adoption/Foster Care of Child
Reason for Leave:
□ Family Member Health Condition*
□ Employee Health Condition*
Leave to start: ____________________
Leave to end: ______________________
Remarks: _______________________________________________________________
Have you taken a FMLA family or medical leave in the past 12 months? □ Yes □ No
OTHER LEAVE INFORMATION
Other Leave Type: □ Maternity (no pay, no benefits unless employee pays premiums)
□ Medical* (no pay, no benefits unless employee pays premiums)
□ Personal (no pay, no benefits unless employee pays premiums)
Leave to start: ____________________
Leave to end: ______________________
□ Yes
□ No
Are you requesting an extension of an existing leave?**
If Yes, indicate type of prior leave: _________________________________________
Reason for leave/Remarks: ________________________________________________
*Attach appropriate documentation from physician
** Please be advised that additional (over 1) extensions will be approved at the Board’s discretion.
SICK DAYS/VACATION DAYS/PERSONAL DAYS
If you intend on using Sick Days, Vacation Days (12 month employees only) and/or
Personal Days prior to the requested leave, please indicate the dates below:
_____ Sick Days
Dates: __________________________
_____ Personal Days
Dates: __________________________
_____ Vacation Days
Dates: __________________________
Employee’s Signature: ___________________________
Date: _____________
TO BE COMPLETED BY CENTRAL OFFICE ADMINISTRATION
Administrator’s Approval: ________________________________
Date: __________
Personnel Administrator’s Approval: ________________________ Date: __________
Board Agenda Date: ____________________ Replacement Needed? □ Yes
□ No
MAIL ORIGINAL FORM TO DAWN IN PERSONNEL AND A COPY TO YOUR SUPERVISOR.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business