Certificate of Leave of Absence Sample by xcv19621

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                  TABLE OF CONTENTS

Introduction                                  3

Leave of Absence information                  4

Steps for filling out Leave of Absence Form   5

Request for Leave of Absence Form Sample      6

Certificate of Absence (COA) Sample           6

Who to Call                                   7


This booklet is to provide employees with some basic information regarding
Leave of Absence and what steps are necessary to request a Leave of

Generally the manager, payroll contact or supervisor is the first one to be
aware of an employee’s absence, either from illness or injury. It is vitally
important that absences are reported in a timely manner and, if needed, that
employees be placed on a Leave of Absence. Being on an approved Leave
of Absence helps protect the employee’s job and helps ensure that their
benefits continue.

                        LEAVE OF ABSENCE

Family Medical Leave of Absence

The Family Medical Leave Act (FMLA) of 1993 allows you to take a leave of absence,
with or without pay, for up to 12 weeks during any continuous 12-month period, for the
following reasons:
    • Birth of a child
    • Adoption of a child
    • Placement of a foster child into your care
    • Caring for your seriously ill child, spouse or parent
    • Your own serious health condition

If you take a family medical leave to care for an ill family member or for your own
serious illness, you may take the leave intermittently, if approved by Personnel.

You are eligible for family medical leave if you have worked for Pinellas County Schools
for at least 1,250 hours during the previous 52 weeks prior to requesting the leave. You
will receive the same group medical and dental rates during your 12 weeks of leave.
When you return from your leave, you will be reinstated to the same or an equivalent

Regular Leave of Absence

You may need to take a leave of absence for reasons that do not qualify under the FMLA
guidelines. These leaves include:
   • Medical Leave-for employees whose medical reasons do not meet the FMLA
   • Professional Leave-for full-time attendance at a college or university (granted
       without pay)
   • Personal Leave-for personal business; granted for short term only (personal and
       vacation time may be used)
   • Child Care Leave-for caring for preschool-aged children; non-illness-related.

The type and length of regular leaves are governed by Union contracts and School Board
policies. Whether you need to take a family medical leave or a regular leave, you must
complete a Request for Leave of Absence form, available at your work location.

If you have any questions or want more information about leave of absence, please
contact the Personnel Department by calling 588-6000 (Administration Building
Operator) and request the Area Representative for support and for instructional personnel,
please contact Sue Sanderson (588-6285 Elementary Instructional Personnel) and
Barbara Ford (588-6000 ext. 1912 Secondary Instructional Personnel).


Fill in all employee information.

   1. Call your payroll technician to determine the number of paid days that you will be
      allowed to use.
   2. Check Leave type.
   3. Beginning (1st full day absent from work) and ending (last full day absent) dates
      must be filled in or the leave request cannot be processed.
   4. If approved for family medical leave, 10 days combined of sick and vacation may
      be reserved. Any other sick and vacation must be used. Employees must indicate
      if he/she wishes to reserve any of the 10 sick and/or vacation days allowed.
   5. Employees with insurance benefits must call Risk Management at 588-6197
      regarding their insurance. While on FMLA, you will continue to receive the
      board contribution. When you are no longer receiving a paycheck, your insurance
      premiums will be billed to you through monthly billing coupons from Risk
      Management. If you fail to make timely premium payments by the due date, your
      insurance will be canceled retroactive to the date through which premiums have
      been paid. When applying for a health insurance waiver while on leave of
      absence, you must have exhausted all vacation and sick hours.
   6. Fill in explanation.

If Employee is unavailable to sign the form, then the Principal/Manager/Supervisor
must sign stating that the employee is unavailable.

For Support Employees:
Manager/Supervisor must sign and check if position is being held or not.
   1. If regular leave is 30 days or less-employee’s position MUST be held.
   2. If regular leave exceeds 30 days-employee’s position will be held at the
      discretion of the manager/supervisor.
   3. Employees on FMLA-the employee’s position MUST be held for 12 weeks.

          Pinellas County Schools


          Pinellas County Schools


                                     WHO TO CALL


   Administration Building Operator                        588-6000
   List of Payroll Technicians with phone extensions


   Instructional Personnel
             Elementary-Sue Sanderson                    588-6285
             Secondary-Barbara Ford                      588-6000 ext. 1912
   Support Personnel
             Administration Building Operator            588-6000
             List of Area Representatives with phone extensions

                                 RISK MANAGEMENT

   Benefits                                                586-6197
            Vicky McClennon
            Theresa Mitola
            Nancy Ramos
            Angela Sempsrott
   Workers’ Compensation                                   588-6196
            Cathy Brannon
            Pat Thomas
   Retirement Insurance and Retirement Programs            588-6214
            Claudette Brown
            Elizabeth Bruce
            Tina Read
            Kim Williams
   Assurant Disability Insurance                           588-6444
   Aetna Representative                                    588-6181
            Michael Kingsley

                                      WEB SITES

Pinellas County Schools--- http://www.Pinellas.k12.fl.us

Human Resources--- http://www.Pinellas.k12.fl.us/HR/

Payroll--- http://www.Pinellas.k12.fl.us/payroll/

Risk Management--- http://www.Pinellas.k12.fl.us/HR/Risk/


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