JEFFERSON COUNTY PUBLIC SCHOOLS by haiSU1

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									                                        JEFFERSON COUNTY PUBLIC SCHOOLS
                                          REQUEST FOR LEAVE OF ABSENCE


             A leave may be taken with approved supporting documentation for the following reasons:

      Medical               Dependent Convalescent                  Child Rearing                Adoption               Military


      Education                         Political                        Qualifying Exigency                Servicemember Family



 Name:

 Social Security #:

 Address:



 Telephone (home ph. #): (with area code)                                     Cell #: (with area code)

 Position:

 Work Location:

Date(s) Leave Requested:
 From:                                                               To:

    Documentation to support the leave request must be attached–Certification of Healthcare Provider--FMLA form


 Signature:                                                                            Date:


NOTE:
Your personnel administrator will determine your eligibility for a leave based on your request and supporting
documentation. Should you have any questions or concerns, please contact: Certified Elementary (3512), Certified
Middle/High (3356), or Classified (3137).

To return from leave you must make the request in writing to your personnel administrator with supporting
documentation.


                  Complete this form and send along with the Certification of Healthcare Provider--FMLA form to:
                                                 Jefferson County Public Schools
                                          Human Resources Department, Second Floor
                                                       3332 Newburg Road
                                                       Louisville, KY 40218




                                                    OFFICE USE ONLY. DATE RECEIVED:

                                                        ____________________

								
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