Fillable AbsenceLOA Request12 13 17 2 000 (Las Positas College)

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AbsenceLOA Request12 13 17 2 000 (Las Positas College)

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S:\FISCAL\JOANNE\(1) working documents\final version posted to website\AbsenceLOARequest 12-13-17.doc
Chabot College Las Positas College District: Hayward Livermore Dublin
(Please Print)
Employee Name: __________________________________________ SSN or W#: ______________________
List each date of absence: ___________________________________ Division/Office:____________________
(indicate hours if absence is less than a full day)
Floating Holiday (Classified – approval of designated supervisor/administrator) [list dates]: ___________________________
Vacation (Classified, Administrators & Executives) [list dates]: _____________________________________
Sick (Administrators & Executives) [list dates]: _______________________________________________
Bereavement Leave state relationship of deceased : __________________________ Destination: __________________________
Judicial Leave (attach copy of summons or notice)
Military Leave (attach copy of official orders)
Family Care Leaves (explain reason): ___________________________________________________
Personal Necessity Leave (Faculty, Classified, Administrators & Executives)
Brief description of need or emergency: ___________________________________________________________________
[Deduct from Sick Leave, refer to respective Bargaining Agreements]
Personal Day (Faculty): ___________________________________________________________________________
Leave without pay and benefits (explain) _________________________________________________________
Furlough Days (Classified, Administrators & Executives) _____________________________________________________
Other (describe): ________________________________________________________________
Leaves Related to Pregnancy/Maternity/Child Birth:
(contact Benefits Office)
. Maternity/Pregnancy Disability (provide Doctor note): __________________________________________________________________
Bonding Leave (must be taken within 1 year of the birth):___________________________________________________________________
Paid Unpaid (using sick leave/differential/extended)
Parental Leave (Maternity and Bonding): _______________________________________________________________________________
Leaves Related to Illness/Sickness (contact Benefits Office)
Request for Family Medical Leave (FMLA) or California Family Right Act (CFRA) (explain or provide Doctor note):
_____________________________________________________________________________________________________
Medical Leave (provide doctor note):___________________________________________________
I certify that leave of absence as requested is for the purpose indicated and further that
such leave will be used as prescribed.
Employee's Signature: ______________________________________________________________ Date: ______/______/______
Recommended Approval
Approved (Floating Holiday) (immediate supervisor / administrator approval only)
Not Recommended/Approved (give reason)
_____________________________________________________________________________________
Supervisor Signature: _____________________________________________________________ Date: ____/____/____
Administrator Signature: ____________________________________________________________ Date: ____/____/____
Submit to: CLPCCD Payroll Department, 7600 Dublin Boulevard, 3
rd
Floor, Dublin CA 94568
Reference: Article 11A, 11A.4, 11B.1c(1),(2), 11B.2, 11C, 11D, 11E.1, 11F, 11G, 11H, 11I Faculty Collective Bargaining Agreement
CHABOT-LAS POSITAS COMMUNITY COLLEGE DISTRICT
Office of Human Resources
Absence: Leave of Absence (LOA) Request or Report
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AbsenceLOA Request12 13 17 2 000 (Las Positas College)

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Completed 24 July 2020

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