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									                             City and County of Denver
                              Parental Involvement Leave Request

                         An employee shall provide Agency HR with notice of the need for Parental Involvement Leave at least seven calendar days in advanced of an
                         academic activity (see activity types in Activity Information section). Such notice shall include written verification from the school or school
                         district of the academic activity prior to use.

                         In case of an emergency where the employee is not aware of the need for leave seven calendar days in advance, the employee
                         shall provide the Agency HR with notice of the leave as soon as possible after becoming aware of the academic activity. Written
                         verification shall be provided upon the employee's return to work the shift following the parental leave. If there is no
                         documentation submitted, the leave will be reversed off the employee's timecard.
                         For assistance filling out this form or for questions regarding your eligibility to use Parental Involvement Leave, please contact
                         your Agency HR Representative.
                         For additional information, please refer to CSA Rule 11-130 Parental Involvement Leave.

                             Department/Agency                                                           Supervisor Name                       Date of Request

                             Employee Name                              Employee ID Number               Supervisor Phone Number
  Activity Information

                                                       Activity        Parent-teacher conference                           Attendance meeting
                             Date of Activity           Type:          Response to intervention meeting                    Truancy meeting
                                                                       Dropout prevention                                   Disciplinary issues meeting

                             Start Time                   Please Note: Written verification of the meeting from the school or school district is required.

                                                               Leave            Vacation                    Comp Time
  Leave Information

                             Total Hours Leave                  Pay:            Sick                        Without Pay
                                                                                Personal Holiday            Donated Sick*
                             Please note: Parental Involvement leave may only be used in 3 hour increments, not to exceed 6 hours per month, 18
                             hours per academic year. Parental Involvement leave is pro-rated for part-time employees.
                             * If an employee is requesting Donated Sick but does not currently have any in his/her donated sick bank, employees must
                             contact their agency HR to start the donated sick request process.

                             Academic Year: Means the period, not to exceed twelve consecutive months, allotted by a school for the completion of
                             one grade level of study.

                             Eligible employee: Includes all Career Service Employees.
                             Eligible employee's child: Means a child who is enrolled in a public school, private school, or in a non-public home-based
                             educational program, in any grade between kindergarten and twelfth grade, from whom the eligible employee is parent,
                             legal guardian, or is acting in the place of a parent.
  Official Use Only

                             Agency HR Representative Signature                        Date         Citywide HR Administrative Services                        Date

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