APPLICATION FOR LEAVE OF AB SENCE
                In accordance with Policies & Procedures Manual HR-006 F, when an employee’s FMLA
                entitlement has expired, or if the absence does not qualify for FMLA, he/she may apply for a
                leave of absence. This leave may be with pay or without pay. Extended leave may be granted
                up to the maximum set forth in the table below based upon the most recent length of
                continuous service with the County at the time the original paid leave commenced. Request
for extended sick leave must include supporting documentation from a physician. All leave of absences must
be approved in advance by employee’s supervisor and/or appointing authority. Final approval rests with the
Appointing Authority and/or the Board of County Commissioners.
                                              Maximum Extended Leave
                       Length of County Service                  Number of Months
                              Up to 2 years                                      1
                              2 years to 4 years                                 2
                              4 years to 6 years                                 3
                              6 years to 8 years                                 4
                              8 years to 10 years                                5
                              Over 10 years                                      6

1. If this absence is due to your own medical condition, you will be required to exhaust all accrued sick,
   annual and personal leaves before being place on an unpaid leave. If this is a nonmedical request for a
   leave of absence, you will be required to exhaust all accrued annual and personal leaves before being
   placed on an unpaid leave.
2. Employees are not eligible for bereavement, accrual of annual (vacation) leave or sick leave while on a
   leave of absence. In addition, if on an unpaid leave of absence, holidays will not be paid.
3. It is your responsibility to apply for use of the Sick Leave Bank if you are eligible and qualify (See policy
   HR-007 S: Sick Leave Bank in your Policies & Procedures Manual).
4. Your insurance(s) contributions will continue to be deducted from your paycheck if you are on a paid leave
   of absence.
5. You will be required to pay your insurance contribution(s) at the biweekly rate due every two weeks if you
   are on an unpaid leave of absence. Failure to pay these contributions may result in termination of your
6. Failure to return from leave of absence on the agreed upon date without an approved extension will result
   in termination of employment for job abandonment.
7. Under no conditions will a leave of absence through multiple extensions exceed one year.
8. All employees returning from a medical leave of absence must provide a physician’s certification of a full
   release, with no restrictions, to return to work. If the employee is released to light duty with restrictions,
   those restrictions need to be detailed on the return to work note and the employee must contact their
   supervisor at least one week in advance of the projected return date to determine if reasonable
   accommodations can be made. (This is a requirement to comply with ADA.)
9. If the dates requested change, a new Application for Leave Of Absence form must be submitted for re-
   approval. If a medical leave of absence is requested, it must be accompanied by an updated physician’s

       I,        , request a leave of absence to begin         and to end       for the following reason: (check one)
             Extension to FMLA                       Medical                   Non-medical Emergency
             Study and/or training                   Running in a primary or general election
             Other (explain)
       I have read and fully understand the information contained on this Application for Leave of Absence.

            Employee’s Signature                                  Print Name                               Date

   Supervisor/Department Head Signature                           Print Name                               Date

                               RETURN COMPLETED FORM TO HUMAN RESOURCES
                                                                                                        LOA Application 3/2005
LEAVE OF ABSENCE CONDITIONS (to be completed by the Human Resources Department)

   1.     Employment Date:
   2.     Eligible for _______ months of LOA based on _______ years of employment
   3.     Last day worked:
   4.     Expected date to return to work:___________________
   5.     As of _____________, accrued leave to be paid:
                  a. Sick Leave            ___________ hours
                  b. Annual Leave ___________ hours
                  c. Personal Leave        ___________ hours
   6.     Is employee eligible and qualify for Sick Leave Bank? [ ] Yes       [ ] No
   7.     Did employee apply for Sick Leave Bank?                  [ ] Yes     [ ] No
   8.     Was application for use of Sick Leave Bank approved? [ ] Yes        [ ] No
   9.     Upon being placed on an unpaid LOA, insurance(s) that are normally deducted from employee’s
          paycheck will be due at the same time as though still receiving a County paycheck. In other words,
          every other Friday.
              a. Medical            [ ] Yes [ ] No         $________
             b. Dental              [ ] Yes [ ] No       $________
             c. Vision              [ ] Yes [ ] No       $________
             d. Prescription        [ ] Yes [ ] No       $________
             e. U.S. Life           [ ] Yes [ ] No       $________
             f.   Colonial          [ ] Yes [ ] No       $________
             g. AFLAC               [ ] Yes [ ] No       $________
             h. Prepaid Legal       [ ] Yes [ ] No       $________
                             Total insurance premium due per pay:              $________
                             Total insurance premium due per month             $________

   Date Leave of Absence Approved:

   Date Letter of approval sent t o employee:

                                                                                           LOA Application 3/2005

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