Norristown Area School District Family & Medical Leave Forms Kit Page 4
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13NORRISTOWN AREA SCHOOL DISTRICT
Staff Leave Request
Payroll/Business Office Copy
Employee:
Social Security #:
Title:
School:
Cole Manor
Paul Fly
Stewart
Gotwals
Whitehall
Roosevelt
Hancock
ENMS
NAHS
Marshall Street
ESTLA
Home Mailing Address:
Phone#:
Requested Start Date:
Anticipated Return to Work Date:
Intermittent or reduced work schedule requested (please describe):
A leave of absence may consist of leave without pay and/or paid leave (e.g. vacation, sick leave, or
compensatory time off). Leaves may be used in accordance with applicable policies, contracts and agreements
and may be subject to Board approval.
I wish to use leave as estimated below:
Type
# of Days
From
Through
Vacation
Sick Leave
Comp Time Off
Leave w/o Pay
Child Rearing Leave
40-day Differential
Employee Signature:
Date:
Please forward this form to the Office of Human Resources
Staff Leave Request
02/11
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