Fillable APPLICATION FOR LEAVE OF ABSENCE CERTIFICATED SCHOOL-LEVEL EMPLOYEES (Hawaii State Judiciary)

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APPLICATION FOR LEAVE OF ABSENCE CERTIFICATED SCHOOL-LEVEL EMPLOYEES (Hawaii State Judiciary)

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(Page 1 of 2)
I. EMPLOYEE INFORMATION
Last First
Telephone:
School or Sub-Division Code: __ __ __ Leave Code: __ __ __ Bargaining Unit Code: __ __
II. LEAVE REQUEST (Complete appropriate subsection below.)
Family
1
Military
4
Political
5
Other: __________________
Funeral
2
Personal
Sick
3
Health, LWOP
3
Professional Development Vacation
1 2
3
4
5
I hereby request the following type of leave:
Leave with Pay Leave without Pay for the calendar period below:
From: _______________________
To: _______________________
_________________
# of working days
1. Is this an extended leave? Yes No
2. Provide any additional explanation for leave request (attach a separate sheet if necessary):
III. LEAVE APPROVAL
For sick, vacation, and personal leave, Principal/Immediate Supervisor approval required.
Approved
Not Approved
Approved
Not Approved PRO/CAS Signature:
IV. LICENSED PHYSICIAN'S STATEMENT
I certify that ____________________________________ is under my care for health reasons and is not physically able to perform
his/her normal work duties from _______________________ to ______________________.
Date:
School/Office:
Position:
Date:
For family, military, professional, and political leave, both Principal/Immediate Supervisor and PRO/CAS approval required.
MM/DD/YYYY
Complete and attach Federal Form WH-380F
or WH-380E(Sde).
Complete Licensed Physician's Statement by completing Section IV
at bottom of this form for Health leave or if Sick leave for more
than five (5) consecutive days or submit a signed doctor's note
verifying current health condition. Approval for sick leave is
subject to the availability of accumulated sick leave.
Provide relationship to deceased and address if out of state in #2
below.
Attach a copy of your military orders with this form (copy) to OTM
Employee Records and Transactions Section, Certificated.
Attach a separate letter justifying political appointment.
MM/DD/YYYY
MM/DD/YYYY
M.I.
Zip:
State:
City:
Address:
Type of Practice:
Name of Licensed Physician (Print):
Address:
MM/DD/YYYY
MM/DD/YYYY
Telephone #:
APPLICATION FOR LEAVE OF
ABSENCE CERTIFICATED
SCHOOL-LEVEL EMPLOYEES
DOE OTM 300-001
Last Revised: 10/18/2019
Former DOE Form(s): DOE OHR 300-001
DEPARTMENT OF EDUCATION
Office of Talent Management (OTM)
Employee Records and Transactions Section, Certificated
P.O. Box 2360 Honolulu, HI 96804
DOE Employee ID:
Name:
Distribution: Leave with Pay (Teachers): 1. Original - School; 2. Copy 1 - Employee; 3. Copy 2 - PRO (if leave exceeds one month) / Leave With Pay (EOs): 1.
Original - School; 2. Copy 1 - Employee / Leave Without Pay and Military Leave With Pay: 1. Original - OTM, Employee Records and Transactions Section,
Certificated; 2. Copy 1 - Employee; 3. Copy 2 - School; 4. Copy 3 - PRO; 5. Copy 4 - Payroll Office, Leave Accounting Section
(To be completed ONLY for HEALTH LEAVE or if SICK LEAVE is for more than five (5) consecutive work days)
Date:
MM/DD/YYYY
Principal/Immediate
Supervisor Signature:
MM/DD/YYYY
Date:
MM/DD/YYYY
Licensed Physician Signature:
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(Page 2 of 2)
INSTRUCTIONS
1. All leave requests should clearly state reasons and pertinent details.
2. A separate DOE OTM 300-001 form should be submitted for each type of leave requested with the applicable dates documented.
3. All extended leaves must be for the SAME REASON as the original leave.
4.
5.
ROUTING FOR ALL LEAVE WITH PAY
For teachers only:
1.
Teacher calls in absence to the Teacher Substitute Employees Automated System (T-SEAS) and
2. Teacher completes the DOE OTM 300-001 form for the principal or immediate supervisor's approval.
3. For absence(s) called into T-SEAS, school files and keeps the original form.
For absences(s) not called into T-SEAS, school files and keeps the original form. Also, school reports and inputs absence(s) into T-SEAS.
For school level educational officers (EOs) only:
1. Employee completes the DOE OTM 300-001 form for the principal/CAS approval.
2. School inputs approved leave of absences in Kronos Time & Attendance Data System and files the original form.
ROUTING FOR ALL LEAVE WITHOUT PAY AND MILITARY LEAVE WITH PAY
1. The employee submits the DOE OTM 300-001 form and supporting attachment(s) to the principal or immediate supervisor.
2. Employee reports all absences in T-SEAS. If employee is unable to report absence, SASA/timekeeper will report absence.
3.
4.
GENERAL INFORMATION
A. Employee Responsibility While On Leave
1.
2.
3.
B. Requesting Early Return From Leave (Reference: Department's Procedures and Regulation #5400)
Prior to returning to work, the employee must submit a written request to the Office of Talent Management specifying the following:
1.
Date of availability
4. School/office from which leave was taken
2. Acceptable school/office locations 5. Teaching specialty (e.g., elementary, secondary, English, etc.), if applicable
3. Present period of leave (beginning and ending dates) 6. Present telephone number and address
C. Failure to Return to Duty
If requesting early return from leave for health reasons, the employee also submits a medical examination clearance such as a doctor's note
stating employee is physically fit to return to his/her duties.
Unless additional leave is granted, an employee who fails to return to service upon expiration of his/her leave will be terminated. All
guarantee rights are forfeited upon termination.
When requesting leave without pay for health reasons or if sick leave is more than five (5) consecutive work days, attach a licensed
physician's statement or note verifying the employee's health condition. A separate licensed physician statement may be accepted for
leave with pay for more than five (5) consecutive work days if the following statement is provided: "I certify that (Name of Employee)
is under my care for health reasons and is not physically able to perform his/her normal work duties
from _______ to _______."
If leave is requested because of critical illness or death in the immediate family, the name, residence, and the exact relationship must
be given. In addition, if for critical illness in the immediate family, then an accompanying statement clearly stating the imperative need
of the employee's presence at the bedside is needed.
Exception : For long-term leave of absence with pay for one month or more, employee and school process request as noted aboveand
school forwards a copy of the DOE OTM 300-001 form to the Personnel Regional Office.
The principal or immediate supervisor, after recommendation for approval, submits the original DOE OTM 300-001 form and any
supporting attachment(s) to the Personnel Regional Officer.
The following is provided as general information. Employees are advised to review the specific regulations and procedures in the Department's
Procedures and Regulations to understand the terms, conditions, and employee responsibilities that apply to their leave situations.
The Personnel Regional Officer, after approval action, sends the original form with any attachments to the OTM, Certificated Employee
Records and Transactions Section and makes copies and distributes according to the distribution line noted in the footer of the form.
Keeps the Department informed of intent to return by writing and submitting directly to the Department (school principal or
Personnel Regional Officer) at least ninety (90) days prior to the expiration date of his/her leave.
Keeps the Department informed of current leave address to ensure that he/she receives all correspondence sent to him/her by the
Department.
Initiates direct monthly payment(s) to maintain Health Fund Benefits as required during leaves of absence without pay.
APPLICATION FOR LEAVE OF
ABSENCE CERTIFICATED SCHOOL-
LEVEL EMPLOYEES -
INSTRUCTIONS
DOE OTM 300-001
Last Revised: 10/18/2019
Former DOE Form(s): DOE OHR 300-001
DEPARTMENT OF EDUCATION
Office of Talent Management (OTM)
Employee Records and Transactions Section, Certificated
P.O. Box 2360 Honolulu, HI 96804
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APPLICATION FOR LEAVE OF ABSENCE CERTIFICATED SCHOOL-LEVEL EMPLOYEES (Hawaii State Judiciary)

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Completed 10 November 2020

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