Employee Name:

Employee ID Number:

Please use complete legal name

Work Location:

Position:

Please list all positions (teacher, coach, etc.)

I request a leave of absence for the period of:

Full Time Leave:

to

Part Time Leave:

Expected first day off work

Expected first day back to work

(If part time leave list hours per day

)

For the following reason:

Adoption of a child

Professional

Maternity*

Family Illness (please list family member and relationship)*

Childcare

Medical*

Military (copies of official orders are required)

Other (please list reason)

*

Maternity, medical and family illness leaves require a physician’s certificate before leave can be approved.

Please indicate

Please circle

number of days

I would like to use my available sick leave (if applicable) for this leave request

Yes

No

I would like to use my available vacation leave (if applicable) for this leave

Yes

No

I would like to use my personal leave (if applicable) for this leave request.

Yes No

I have entered this leave of absence into the employee absence reporting system. The job number is:

. I un-

derstand that if the leave dates change it is my responsibility to ensure that the days are reported into the employee absence

reporting system and that a substitute is arranged for, if applicable.

I also understand that entering this absence into the em-

ployee absence reporting system does not constitute approval of this leave of absence.

I understand that this request for a leave of absence is subject to the terms and condition of my collective bargaining agreement

and/or Board Policy. I also understand that Human Resources determines final approval of this request and that if I need to

revise my return to work date I will notify Human Resources, in writing, and provide an updated physician’s certificate if re-

quired.

Employee Signature

Date

Recommend

Not Recommend

Supervisor/Principal Signature

Date

Approved

Denied

Human Resources

Date

Distribution: Original—Leave File HR Records HR Substitute Services Payroll Principal/Supervisor Employee

Revised 05.06.2005