CCS Request For Leave of Absence Form

Request for Leave of Absence

Please note: Leave will not be considered approved until this form is completed, FMLA Forms, and medical certification has been received
Name*

First NameLast Name
Employee/Timekeeper ID*
Email*
example@caldwellschools.com.com
Phone Number*

Area CodePhone Number
Position*
Location*
Principal/Director's Name*

First NameLast Name
Principal/Supervisor Email:*
example@caldwellschools.com
Family Medical Leave

Employee must be employed with CCS for at least 12 months (not necessarily consecutive) and worked at least 1250 hours during the previous 12 months. FMLA is available for up to 12 weeks in a 12-month period, beginning on the date leave begins. Eligible paid leave will be used concurrent with FMLA leave.
Beginning Date of Leave*

MonthDayYear
Ending Date of Leave*

MonthDayYear
Type of Leave Requested: (Check One)*

Serious Health Condition/Disability (Form WH-380-E)Birth, Adoption, Placement of Child (Form WH-380-E)Care for Spouse, Child or Parent with Serious Health Condition (Form WH-380-F)Military Service Exigency (Military documentation required and form WH384)Care for a Service Member who has a Serious Illness or Injury (Military documentation required and form WH384)Intermittent Leave (Form WH-380E or WH380F)Educational Leave Without Pay (Eligible after 12 months of continuous, full-time employment. Leave must be requested and approved in advance)Leave Without Pay - Including but not limited to employees who do not qualifying for FMLA. Please put in writing your reason (below) for this request and attach applicable documentation.
You are needing to care for your family member due to a serious health condition. Your family member is your:

SpouseParentChild under age 18Child 18 years or older and incapable of self care because of a mental or physical disability
A qualifying exigency arising out of the fact that your family member is on covered active duty or has been notified of an impending call or order to covered active duty status. Your family member on covered active duty is your:

SpouseParentChild of any age
You are needed to care for your family member who is a covered servicemember with a serious injury or illness. You are the servicemember’s: :

SpouseParentChildNext of kin
Leave without pay reason:
Additional Information/Comments:
File Upload

Cancelof
FMLA/Leave Without Pay:
Please note: Sick leave, voluntary shared leave, and extended sick leave can only be used during the actual period of temporary disability as certified by your Physician.

During your leave, we will use your available days in the following order unless you notify us otherwise: sick leave, annual leave, voluntary shared leave (if available), extended sick leave (if available), personal leave, leave without pay.

Extended sick leave and personal leave are only available to classroom teachers and media specialists requiring a substitute.

Insurance benefits shall be covered by Caldwell County Schools for the employee only during the Approved FMLA leave period (12 work weeks per year) provided that the employee returns to employment with Caldwell County Schools. After expiration of the employee’s FMLA coverage, the school system shall not continue paying the employer’s portion of health insurance. These coverages become the employee’s responsibility

If an employee exhausts all leave and "goes off payroll," the employee will be responsible for payment of any Benefits (dental, vision, life insurance, and other colonial products)

** I have read and understood applicable Board Policies (7510 Leaves, 7520 Family and Medical Leave, 7530 Military Leave, & 7540 Voluntary Shared Leave) and will adhere to all notice and certification requirements included therein. I also understand if any dates change, I will immediately contact my Human Resources Specialist to verify and submit and necessary revised doctor's notes.
Employee Signature

Clear
Should be Empty:

Request for Leave of Absence

Family Medical Leave