Request for Short Term Leave

Belleville Area Special Services Cooperative Phone (618) 355-4700

2411 Pathways Crossing, Belleville IL 62221 Fax (618) 355-4415

REQUEST FOR SHORT TERM LEAVE

All leave requests must be pre-arranged and require written approval unless emergency prohibits. Requests are considered for compliance with the BASSC Union Contract provisions and/or the impact of the absence to the BASSC mission. Notify the local district administrator(s) whose program(s) may be affected by this request. Submit requests to your BASSC supervisor. Attach necessary documents/add necessary clarification on the back of this form.

Substitute required? No Yes Specify dates:

FUNERAL LEAVE: Dates(s) requested as Funeral Leave: Indicate the eligible “immediate family” member (as defined by the Illinois School Code):

Parent Spouse Brother Sister Child Grandparent Grandchild

Parent-in-law Brother-in-law Sister-in-law Legal Guardian

JURY DUTY LEAVE / COURT SUBPOENA: Date of Jury Duty per Summons:

There will be no loss in BASSC pay for jury duty, subpoena to attend as witness for trial, or for deposition taken in any school – related matter subject to the following conditions (provide EACH of the following):

____ A copy of the summons/subpoena is attached. Date subpoena received:____________ by:

____ 5 day notice provided to BASSC (unless court subpoena is less than 5 days to appear).

____ Other payment for jury duty/witness/deposition endorsed and provided to BASSC. Received

FAMILY MEDICAL LEAVE ACT (FMLA) REQUEST: Scheduled Working Date(s) Requested as leave:

Qualifying Medical Event:

OTHER LEAVE REQUEST: Scheduled Working Date(s) Requested as leave:

Specify reason:

Staff Member’s Signature Name (Print) Date

Local District Administrator Notified of Request (Local Admin. Signature): Date:

BASSC Supervisor’s Review: Date:

Approved Not Approved – reason:

Request for Short Term Leave.doc 05/18/09 Page 2 of 1