Everett Public Schools

Leave Request Form

Employee Name:           Position       School/Dept      

Original Request  [  ]  Revised Request  [  ]

I request authorization to be absent from work for the following period:  

 

  day(s) with pay       day(s) without pay

Below please indicate the type of leave:

 

*Maternity and/or Medical leaves require a Physician’s Certification Form

Shared Leave Pool Request

I am requesting     days from the shared leave pool for a serious medical condition.

I have read and understand the criteria for the Shared Leave Program which will be used to determine my eligibility to participate in the Leave Share Program

[  ] Approved for ________ day(s)       [  ] Denied

 

Substitute Information (if applicable):

I have arranged for a substitute for my absence. The Job Number is      . I understand that if the leave dates are changed, it is my responsibility to ensure there is coverage for my absence.

 

I understand that this leave request is subject to the terms and conditions of my collective bargaining agreement and/or Board Policy. I also understand that the Human Resources Department determines final approval and any revision to an approved leave requires the completion of a revised Leave Request form.

 

Employee Signature:                 Date:          

 

 

Recommend   Not Recommend                         

            Supervisor/Principal Signature       Date



Approved     Denied