Leave of Absence Application
(Please print information and forward to Human Resources)
Employee Information
Name: Home Address: _______________________________________ Job Title: _____________________________________ Location: ____________________________________ _______________________________________ ID #: ____________________________ Phone #: ________________________
Section A
I am requesting the following Leave of Absence: Start date*: ___________________________ Anticipated date of return*: ___________________________
Reason for Leave of Absence*: _________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________
*information is required to process application
BOARD POLICY GBGH: FEDERALLY-MANDATED FAMILY LEAVE The provisions of this Policy shall apply to all Family and Medical Leaves of Absence and provide eligible employees with up to a total of twelve (12) work weeks of unpaid leave in a twelve (12)-month period. Federally-Mandated Family Leave is administered concurrently with any paid leave or vacation covered under other Board Policies or the ATU for any part of the twelve (12) weeks of leave to which the employee is entitled. An employee who qualifies for paid leave or vacation under another policy or the ATU shall take the paid leave or vacation concurrently. To be eligible for leave under this policy, an employee shall have been employed for at least twelve (12) months and shall have worked at least one thousand two hundred and fifty (1,250) hours during the twelve (12)-month period preceding the commencement of the leave. An eligible employee shall be entitled to a combined total of twelve (12) weeks' leave per year under particular circumstances that are critical to the life of a family.
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Leave may be taken upon the birth and for the first-year care of the employee's child; upon the placement of a child with the employee for adoption or foster care; when the employee is needed to care for a child, spouse or parent who has a serious health condition; or when the employee is unable to perform the functions of the position because of a serious health condition. Entitlement for child care leave shall end after the child reaches age one (1) or twelve (12) months after adoption or foster placement. Leave to care for a child shall include leave for a step-parent or person in loco parentis. If medically necessary for a serious health condition of the employee or the employee's spouse, child or parent, leave may be taken on an intermittent or reduced leave schedule subject to certain conditions which pertain to instructional employees. The District may require the employee to transfer temporarily to an alternative position which better accommodates recurring periods of absence or a part-time schedule provided that the position has equivalent pay and benefits. The District shall maintain coverage under any group health insurance plan for any employee who is granted an approved leave of absence under this Policy for the duration of the leave (up to twelve [12] weeks). Such coverage shall be maintained at the same level and under the same conditions as coverage would have been provided if the employee were not on leave. The District reserves the right to seek reimbursement for this benefit in the event that an employee elects not to return to work, as allowed by law. Reinstatement shall be determined in accordance with any applicable Board Policies or the ATU. If the employee on leave is a salaried employee and is among the highest paid ten percent (10%) of District employees and keeping the job open for the employee would result in substantial economic injury to the District, the employee may be denied reinstatement provided the District notifies the employee of its intent to deny reinstatement at the time economic hardship occurs and the employee elects not to return to work after receiving the notice. The Superintendent is directed to develop procedures to require appropriate medical certifications, notification and reporting which are consistent with law. The procedures shall describe how the District will post notices concerning the federal law and other steps the District shall take to inform employees of its requirements.
Section B
Total number of scheduled work days to be missed while on leave of absence: ____________ Please read the following statements carefully and check the box as it applies to your application for a leave of absence:
I request my Annual Leave be used for days missed. Total number of Annual Leave hours/days I have: ___________ I request my Vacation be used for days missed. Total number of Vacation hours/days I have:
___________
I am a member of the Sick Leave bank and am requesting Sick Leave for the following number of days: ___________ (Please attach your Sick Leave Bank request to this application) I am requesting Compassionate Leave for the following number of days: (Please attach your Compassionate Leave request to this application) I am requesting leave without pay for the following number of days**:
___________ ___________
I am requesting that my entire leave of absence be leave without pay. (Please note: employees requesting FMLA will be required to use their accrued annual leave and/or vacation.)
** Any days missed not covered by annual leave, vacation, sick leave or compassionate leave will be unpaid.
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Section C
Employee Statement: In accordance with Board Policy GBGE, I am requesting leave of absence of 5 or more consecutive days. I have discussed this leave of absence with my supervisor and obtained her/his signature on this application. I understand that it is my responsibility to report days missed in SAM (School Absence Manager) for the duration of my leave. If I am unable to return to work on the date stated in Section A, I will apply for an extension to my leave of absence. Before returning to work from my leave of absence, I will contact Phyllis Nies at 579-2027 (if licensed) or Marnie Ballard at 579-2022 (if Educational Support Personnel) to confirm my return to work date and ensure payroll reinstatement. My signature below indicates I am applying for a leave of absence. I have read the employee statement and understand my responsibilities. Employee Signature ____________________________________________________ Date _________________________ ******************************************************************************************** I (check one) _____approve _____disapprove this leave of absence application. If approved, the employee’s days missed have been reported in SAM. Supervisor or Principal Signature ___________________________________________________ Date __________________________
******************************************************************************************** ______ Approve ______ Disapprove
Human Resources Signature ___________________________________________________ Date _________________________
(Human Resources Use Only) Placed on Board Agenda: FMLA eligible: FMLA Notification Sent: Sick Leave Bank Granted: __________ __________ __________ __________ Dates Requested: __________ to __________ Dates Requested: __________ to __________ Date of Leave without pay (if applicable) __________ Leave entered in SAGE: Copies Made: ______ ______
Compassionate Leave Granted: __________ Payroll Adjustment Needed: __________
Employee Actual Return Date: __________
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