Request for Health Leave of Absence by ild18893


									                                         Denver Public Schools
                                 Request for Health Leave of Absence
                                             (To be completed by employee)
Name:                                                                           Date of Request:
Home Address: __________________________________________                        City: ________________ZIP ___________
Home Phone: ___________________________________________                         School/Dept:
Position: _______________________________Employee ID #:                      100                   Last 4 SSN: ________

1. Complete form.
2. Notify principal/supervisor.
3. Take the appropriate Medical Certification Form to your health care provider for completion. You must furnish
   certification within fifteen (15) days from the date of this notification. Please put “DENVER PUBLIC
   SCHOOLS, HR Connect, 720-423-3900, FAX: 720-423-3853” as employer name and contact on the certifi-
   cation form.
4. Refer to your most recent paycheck stub for current sick and vacation day balances.
5. Send all completed forms to: Denver Public Schools/Attn: Employee Health Services, Room 105
                                900 Grant Street, Denver, CO 80203 or fax to 720-423-3853
I request the following health leave of absence for:         Personal Illness
                                                             Family Illness
                                                             Maternity/Paternity
                                                             Military Family Leave (may require additional verification)

Beginning date or anticipated start of leave:
Ending date or expected end of leave:

Paid Benefits Requested (check all that apply)-Current balances are shown on your most recent
pay stub.
_____ Sick Days .................................... Current balance __________ hours
_____ Vacation Days............................. Current balance __________ hours
_____ *Sick Leave Bank ....................... Date eligible ____________________
* requires additional application form

Leave Requested, (with or without pay)
_____ Family and Medical Leave Act (FMLA) Leave (runs concurrent with DPS leaves, if applicable)
_____ DPS Maternity/Paternity Leave
_____ DPS Extended Medical Leave
_____ DPS Family Illness Leave

Employee Signature:                                                                     Date:

Principal/Supervisor must be notified of your request. I have ______ have not ______ notified my princip-
al/supervisor whose name is ____________________________________________________.

  Employee Health Services
  Date request received: ____________________________ Date all required paperwork completed: ___________________
  Leave Notification Letter sent:______________________ Approved ________________ Denied____________________

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