Leave Application Form - New York City Department Of Education

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New York City Board of Education
Division of Human Resources
Bureau of Paraprofessional & Hourly Non-Competitive Appointments
65 Court Street – Room 501 ▪ Brooklyn, New York 11201
EDUCATIONAL PARAPROFESSIONAL LEAVE APPLICATION
This application is to be utilized for initial requests for leaves of absence as well as requests for extensions.
Requests for extensions must be submitted prior to the date of expiration of current leave.
PERSONAL INFORMATION (Please Print – Use Blue or Black Ink Only)
NAME: (Last, First, Middle Initial)
START DATE: (mm/dd/yy)
/
/
SOCIAL SECURITY #:
EIS # (If Known):
Home Phone:
(
)
MAILING ADDRESS: (Street, Apt #, City, State, Zip Code)
DISTRICT/FMC:
SCHOOL:
EMPLOYEE SIGNATURE:
DATE:
- All leaves are without pay. To be eligible for health related leaves, all sick time balances must be exhausted.
CHECK ONE LEAVE CATEGORY ONLY
STUDY: (Max. 1Year – 3 years UFT Seniority Requirement)
PERSONAL ILLNESS or PREGNANCY RELATED
Attach original letter with raised seal from the
DISABILITY: (Max. 1 Year- No Seniority
Registrar’s Office verifying course of study.
Requirement)
Medical Bureau Approval Required.
SERVE AS SCHOOL SECRETARY:
(Max. 1 Year – 3 Years UFT Seniority Requirement)
ILLNESS IN IMMEDIATE FAMILY:
Attach a copy of NYC license and proof of assignment.
(Max 1 Year – 2 Years UFT Seniority Requirement)
Relationship to Employee: _______________________
SCHOOL SECRETARY ASSISTANT PROGRAM:
Medical Bureau Approval Required.
(Max. 18 Months – No Seniority Requirement)
Attach a copy of NYC license and proof of assignment.
MATERNITY/CHILDCARE LEAVE:
(Max. 4 Years – 2 Years UFT Seniority Requirement)
WORKERS’ COMPENSATION (No Seniority requirement)
Attach a copy of the birth certificate for Childcare
Attach a copy of Notice of Injury (Form C-2)
Leave.
MILITARY DUTY (No Seniority Requirement)
TEACH IN NYC PUBLIC SCHOOLS:
Leave commences AFTER the first 22 days of leave
(Max. 1 Year – 3 Years UFT Seniority Requirement)
with pay for ordered military duty (attach a copy of
Attach a copy of NYC license and proof of
military orders).
Assignment.
LEAVE DURATION:
From: _______/_______/________
To: _______/_______/________
CERTIFICATION OF PHYSICIAN OR OTHER AUTHORIZED PRACTITIONER
As a duly licensed physician or other authorized practitioner, I certify that between the dates _____/_____/_____and
_____/______/_____ the person named above will be incapacitated for school duties and that I attended the individual on the
following dates: _______________________________. The technical designation of illness is _____________________________,
.
commonly known as ___________________________________
For Maternity/Pregnancy Related Disability Leave: Expected due date: _______________.
Name of Physician:
:
(Please Print)
Physician’s Address:
__________________________
Street
City_________________State_______Zip Code_________
Physician’s Telephone # (_____)_____-_____________
Signature of Physician: _________________________________________________ Date: _____________
Professional Title (if other than M.D): ________________________________________________________
AUTHORIZING SIGNATURES (Both Signatures are Required)
PRINCIPAL/PROGRAM HEAD:__________________________________________________ DATE:______________
SUPERINTENDENT (OR DESIGNEE):_____________________________________________DATE:______________
_______________________________________________________________
COMMENTS:
DO NOT WRITE BELOW – FOR DEPARTMENT OF EDUCATION MEDICAL BUREAU USE ONLY
The Board of Education Medical Bureau has reviewed medical certification. Approval of this leave is:
NOT RECOMMENDED
RECOMMENDED from the period of _________________ through _______________.
Any request for an extension must be submitted on a new form prior to the date of expiration of the present leave.
SIGNATURE OF MEDICAL DIRECTOR (Or Designated Physician)_______________________________DATE___________

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