Fillable Bereavement Leave Request Form (Central Oregon Community College)

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Bereavement Leave Request Form (Central Oregon Community College)

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WP\FMLA - OFLA\OFLA Forms- OFLA Bereavement Request Form
An employee who wishes to take time off due to the death of an immediate family member should notify his or her
supervisor immediately. Bereavement leave shall be noted on the employee’s timesheet or time off request form for
Payroll, and a Bereavement Request Form (following) should be completed and submitted to the HR Department.
A) To be eligible for bereavement leave protected under the Oregon Family Medical Leave Act (OFLA), an employee
must meet the following four requirements:
1) Be employed by the college for a minimum of 180 days immediately prior to the onset of the leave; and
2) Have worked a minimum average of 25 hours per week for the 180 days immediately prior to the onset of the
leave. These are actual worked hours, and do not include sick leave, vacation, etc. per the guidelines set out
pursuant to the Fair Labor Standards Act (See 29 CFR §785); and
3) Have not exhausted all 12 weeks of OFLA protected leave within the past 12 months immediately prior to the
onset of the leave; and
4) Need time off due to the death of a family member as *defined in the OFLA*.
B) Under OFLA only an eligible employee may take up to two weeks of leave to deal with the death of a family member*
by:
I. Attending the funeral or alternative to a funeral of the family member
II. Making arrangements necessitated by the death of the family member
III. Grieving the death of the family member
C) The leave must be completed within 60 days of the date on which the eligible employee receives notice of the death
of a family member.
D) An employee on OFLA bereavement leave must use accrued paid time (sick and/or vacation) prior to going unpaid.
E) The employee is entitled to take multiple periods of bereavement leave concurrently or separately if more than one
family member of the employee dies during the one-year period.
F) Bereavement leave used is deducted from the employee’s overall up to 12 week OFLA entitlement, and
cannot exceed the entitlement.
G) Two or more eligible family members who are employees are allowed to take bereavement leave at the
same time for the same family member.
H) Refer to relevant collective bargaining agreement and COCC policies.
*"Family member" means the spouse, same-gender domestic partner, custodial parent, non-custodial parent, adoptive
parent, foster parent, biological parent, parent-in-law, parent of same-gender domestic partner, grandparent or
grandchild of the employee, or a person with whom the employee is or was in a relationship of in loco parentis. It also
includes the biological, adopted, foster or stepchild of an employee or the child of an employee’s same-gender domestic
partner. Additional relations may qualify as a ‘Family member’ under the relevant collective bargaining agreements.
For additional information regarding your rights and responsibilities under OFLA or the relevant collective bargaining
agreements, please contact Human Resources at 541-383-7216.
COCC Bereavement Leave Procedure
WP\FMLA - OFLA\OFLA Forms- OFLA Bereavement Request Form
Bereavement Leave Request Form
Employee Information:
Name: Today’s Date: _____________________________
Title: ______________________________________ Phone Number: ____________________________
Address: COCC ID#: 820____________________________
Hours: FT_____ PT_____ Other____
Date of Hire: Supervisor:
Classification: Classified Faculty Administrative ABS Department:
Name of the Deceased
Relationship to Employee
Employee Signature Supervisor Signature
If leave is taken on an intermittent basis, (2 weeks
total within 60 days of notice) please provide
schedule here, if known:
.
.
.
.
.
.
.
.
.
Date of Knowledge of Death:
Beginning Date of Leave:
Date Returning to Work:
Date Supervisor Notified:
*For HR Use Only*
☐ Eligible for leave protected under OFLA ☐ Eligible for leave protected under CBA
If yes, total amount allowed:____________ If yes, total amount allowed:____________
☐ Not eligible for leave protected under OFLA ☐ Not eligible for leave protected under CBA
Reason, if not approved: _____________________________________________
HR Representative Signature
Cc: Employee
Human Resources
WP\FMLA - OFLA\OFLA Forms- OFLA Bereavement Request Form
COCC Human Resources Office
Phone: (541) 383‐7216
FAX No: (541) 317‐3066
TDD No: (541) 383‐7708
LEAVE REQUEST FORM
Employee _______________________________________________________________ Date: ______________________
COCC ID # ____________________________________________________________________________________________
Department __________________________________________________________________________________________
Dates/Hours Requested ____________________________________________________________________________
________________________________________________________________________________________________________
Type of Leave:
REMINDER: EMPLOYEES MAY NOT UTILIZE VACATION LEAVE DURING THE FIRST SIX
MONTHS OF EMPLOYMENT.
If "vacation" time is requested within the first 6 months, the approved time off must be applied as
‘Leave Without Pay’.
☐Vacation ☐Comp time ☐Leave Without Pay ☐Bereavement* ☐Emergency Leave
☐Personal Leave (Faculty requests require VPI approval)
* If Bereavement Leave is requested, please also complete the Bereavement Leave Request form
Employee Signature: ___________________________________________________ Date_______________________
Supervisor’s Signature: ________________________________________________ Date_______________________
INSTRUCTIONS:
1. All leave requests must be APPROVED before the leave is taken.
2. The employee and Supervisor each keep a COPY of the approved request.
3. The SUPERVISOR SENDS the approved leave form to Payroll in Newberry Hall.
4. If the approved time is not taken, it is the employee’s responsibility to submit a revised leave
request form to the Supervisor for signature and forwarding to Payroll.
5. Classified staff must report approved leave on monthly time sheets.
Please print this form, fill out, sign and send to:
Payroll – Newberry Hall
2600 NW College Way
Bend, Oregon 97701‐5998
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Bereavement Leave Request Form (Central Oregon Community College)

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Completed 21 July 2020

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