DOE OHR 300-001
Last Revised: 01/01/2011
Former DOE Form(s): 400, 400a, 400a.1, 400F
DEPARTMENT OF EDUCATION
O fice of Human Resources
Records and Transactions Section, Certificated
P.O. Box 2360 Honolulu, HI 96804
I. EMPLOYEE INFORMATION
Name: _____________________________________________________________ Last 4 digits of SSN: _____________________
Last First M.I.
Address: _________________________________________ City: _____________________ State: _______ Zip: ______________
Tel#: ________________________
Position: _________________________
School/Office: ______________________________
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
Personnel 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
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
OHR, Records and Transactions Section, Certificated.
Attach a separate letter justifying political appointment.
APPLICATION FOR LEAVE OF
ABSENCE CERTIFICATED
SCHOOL-LEVEL EMPLOYEES
MM/DD/YYYYMM/DD/YYYY
(Page 1 of 1)
1. Is this an extended leave? Yes
o
2. Provide any additional explanation for leave request (attach a separate sheet if necessary):
________________________________________________________________________________________________________
Employee Signature: _______________________________________________________ Date: _______________________
III. LEAVE APPROVAL
For sick, vacation, and personal leave, Principal/Immediate Supervisor approval required.
Approved
ot Approved __________________________________________ Date: _________________
Approved
ot
pprove
PR
gnature: ________________________________________ Date: _______________
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 ______________________.
L
cense
P
ys
c
an
gnature: ________________________________________ Date: _______________________
ame of Licensed Physician (Print): __________________________________ Type of Practice: ___________________________
Address: __________________________________________________________
Te
: ____________________________________
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 - OHR, 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)
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
For family, military, personnel development, and political leave, both Principal/Immediate Supervisor and
PRO/CAS approval required.
MM/DD/YYYY
MM/DD/YYYYMM/DD/YYYY
Principal/Immediate
Supervisor Signature:
(Page 1 of 1)(Page 1 of 1)
