5:185-E1 Leave Calculation Worksheet

On District Letterhead

Leave Calculation Worksheet

In preparing to request a leave of absence please take time to complete the worksheet below. The intention of this sheet is to provide both you and the district accurate information concerning your leave request. Remember that you will need to submit a formal letter to the Assistant Superintendent of Human Resources requesting your leave. The leave will only become official after it is approved by the Board of Education. Unless emergency circumstances preclude it is requested that your formal letter be submitted to the Assistant Superintendent of Human Resources no less than 60 days prior to the start of your leave.

Name:______________________________________________________

1. Type of Leave:

      _______Medical/FMLA

      _______Child Rearing

      _______Other (specify):__________________________________

2. Leave Start Date:___________

3. Return to Work Date:_______________

4. Number of Work Days On Leave:_________________________

5. Number of Paid Sick Days Applied to leave:_____________________

6. Number of Unpaid Days Applied to leave:_________________________ 7

7. Will you maintain your insurance during leave: _____Yes _____No

*Note – Employees on unpaid leave that wish to maintain membership in the BEA/IEA/NEA are responsible for dues and will be billed by the Association for each missed payroll deduction during the unpaid period. Employees are responsible to pay insurance premiums during any unpaid period.

*Note II – If you have questions about the distribution of pay during a LOA you will need to work with Steve Pearce, Assistant Superintendent of Human Resources.

Dated Adopted:   4/7/2009

Date Amended:   3/18/2015