BEREAVEMENT LEAVE REQUEST FORM - Download as DOC

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					                   BEREAVEMENT LEAVE REQUEST FORM
                                     Classified Staff in Bargaining Unit 1

 Classified Staff in Bargaining Unit I: In accordance with the Bargaining Unit I Contract, Section 32.4, up to three
 days of paid bereavement leave (code 240) is available for the death of the employee's family member, or domestic
 partner. It is also available for corresponding family members of the employee's spouse or domestic partner.
 Family member is defined as parent, sister, brother, spouse, mother-in-law, father-in-law, grandparent, grandchild,
 son, daughter, stepchild, a child in the custody of and residing in the home of an employee. Domestic partners are
 defined as persons who reside in the same home who have reciprocal duties to and do provide financial and/or
 emotional support for one another. In addition, in accordance with Section 51.2.4, sick leave (code 180) may be
 requested for bereavement and is limited to three days for death of a family member as defined above. Sick leave is
 not available for bereavement or condolence for a non-family member.

 Instructions: complete and submit along with the green REQUEST FOR OR REPORT OF ABSENCE form.


 DATE:            _____________________________

 TO:              _____________________________, Supervisor

 FROM:            _____________________________
                  (Print Employee Name)

 SUBJECT:         Bereavement Leave

 I am requesting ____________________ day(s) of bereavement leave on the following dates:

 ________________________________________________________ due to the death of my

 ___________________________________ who died on (date) ______________________.

 The funeral will be held on (date) ______________________________________________,

 in (city, state) ______________________________________________________________.

 Your consideration in this matter is appreciated.

 ___________________________________________
 (Employee Signature)

APPROVED:
                         (Supervisor)                                                     (Date)


                         (Department Head)                                                (Date)




 Bereavement Leave BUI revised 9/05

				
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