Rev 01 05 15
C
h
af
f
e
y
C
o
ll
eg
e
MONTHLY LEAVE BALANCE
STATEMENT
FOR CLASSIFIED, CONFIDENTIAL, MANAGEMENT, PROFESSIONAL EXPERTS,
AND CHILD
DEVELOPMENT CENTER
TEACHERS
Last Name First Name
/
Colleague ID Number Department Month Year
GENERAL INSTRUCTIONS
A Monthly Leave Balance
Statement
is to be completed at the en
d
of
each month and submitted to
Payroll
no later than the third (3rd)
working day of the following month. The statement is to
be
completed by each employee regardless of whether any time was
taken or not.
EXPLANATION OF CODES
Sick Leave-leave codes below are deducted from the sick leave balance
S Sick Leave
PN Personal Necessity Leave
(CSEA: state applicable
subsection under comments-choose 15.7.1, 15.7.2, 15.7.3 or
15.7.5)
PB Personal Business
PFC Family Care Leave
(deducted from personal necessity, state
reason under “comments”)
FSP Family School Leave – use personal necessity
FSV Family School Leave – use vacation
FSU Family School Leave – use comp time
accrued
A Absence With Deduction
(requires pre-approval and pay will be
docked)
I Industrial Illness or Accident (must be reported to Risk
Management)
B Bereavement Leave (state relationship of deceased and location
under “comments”)
J Jury Duty (attach verification slip for each day served)
M Military Leave
V Vacation Leave (requires
pre-app
roval)
F Floating Holiday (requires
pre-notification
)
D Differential (Medical Leave – requires doctor’s
c
er
tification)
E Comp Time Worked (requires pre-approval, express actual
hours worked, not 1 ½ x; hours worked will be converted to
1 ½ x
by
Payroll)
U Comp Time Used
C District Assignment (conferences, etc.)
L Sick Leave – Deduct from other form of leave (Human
Resources use only)
COMMENTS:
Day
Code
Length of Absence
Hours Minutes
No absences or Comp Time to report
I certify that to the best of my knowledge, the above information
is complete and accurate.
Employee Signature Date
Supervisor Signature Date
