Paid And/Or Unpaid Leave

Extended Leave Request

Paid and/or Unpaid Leave

Please use this form for all leaves of absence that are FIVE or more days in length or for ANYdays taken as unpaid leave.

EMPLOYEE’S NAME: Click or tap here to enter text.BUILDING/DEPT: Choose an item.

POSITION/TITLE:Click or tap here to enter text.

Date(s) of requested leave: Click or tap to enter a date. Hours Per Day: Click or tap here to enter text.through Click or tap to enter a date. Hours Per Day: Click or tap here to enter text.

If personal day(s) use is/are any part of this request, please list date(s) here: Click or tap here to enter text.

REASON(S) FOR LEAVE (both Paid and Unpaid may be applicable; check both as needed):

PAID Extended Leave of Absence
☐*Medical (disability, injury, surgery, family illness) (please attach Dr. note AND submit signed return to work form upon return. Unpaid leave will be applied once all appropriate paid leave has been exhausted)
☐*Maternity/Paternity
☐*Military (please attach documents)
☐Other (attach a letter explaining specific circumstances)
*FMLA eligibility may apply. Please see FMLA FAQ or contact Human Resources for further information. / UNPAID Extended Leave of Absence
☐Long Term Unpaid leave of absence – 5 or more days (attach a letter explaining specific circumstance – up to one (1) school year leave without pay with approval of the Board of Directors)
☐Short Term Unpaid leave of absence (attach a letter explaining specific circumstance – unpaid leave will be granted ONLY if all appropriate paid leave has been exhausted;)

I have filled out and attached all forms pertaining to my leave request.

Employee Signature: ______Date: ______

Reviewed by Supervisor: ______Date: ______

Comments:______

Request Granted: Yes ☐No ☐FMLA Eligibility: Yes □ No □

Signatures: HR: ______Superintendent: ______

Comments:______

Effective ______Employee has the following accrued leave balances available to use toward this absence:______. Sick: ______Personal:______Vac:______

A Leave of absence without pay may be granted, up to one school year, by the Board of Directors for continued childcare, continued medical or disability, continued education, or for special cases as recommended by the Superintendent.

Leave of absence may be revoked if the employee is no longer engaged in the activity for which the leave was approved.

At the end of the leave of absence, every reasonable effort will be made to return the employee to his/her former position. The employee granted a leave of absence without pay shall inform the Board in writing by March 1 as to his/her intent to assume a position in the district for the ensuing school year. If said written notification is not provided by March 1, the individual’s employment rights with the district may be terminated.

The procedure for filing for an extension would be the same as for applying for the initial leave of absence without pay. No combination of leaves and extensions shall exceed two consecutive years.

Revised 10/2016