Fillable Form 1.: 770 WILSHIRE BOULEVARD AM (Los Angeles Southwest College)

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Form 1.: 770 WILSHIRE BOULEVARD AM (Los Angeles Southwest College)

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LOS ANGELES COMMUNITY COLLEGES
H
UMAN
R
ESOURCES
770 WILSHIRE BOULEVARD
LOS ANGELES, CA 90017
ACADEMIC/CLASSIFIED EMPLOYEE
ABSENCE CERTIFICATION / REQUEST
Use separate form for each absence period and reason for absence. Do not combine multiple reasons on one form.
Please print or type and ensure all information is provided, as omissions can delay processing.
EMPLOYEE TIP SHEET
Last Name
First Name
Employee ID Number
S
ERVICE
:
☐
Academic
☐
Classified
1.
ABSENCE PERIOD:
Dates: Full Days: Part of Day:
☐AM
☐PM
☐AM
☐PM
From
To
Number
From
To
FACULTY UNITY ONLY: For Part of Day Absence Identify Hours of Scheduled Duties Per Day (Including Office Hours):
2.
REASON:
A.
ABSENCE CERTIFICATION:
I certify that I was absent from my duty during the period indicated in Section 1 due to:
☐
Illness or Injury: Indicate nature of illness or injury:
Illness or Injury Absences Instructions
☐
Not the result of Industrial Accident
• Absences over 5 days require Physician Certification
• Absences over 20 days also require Formal Leave of Absence
• Employment elsewhere while on any illness/injury absence
prohibited.
☐
Result of Industrial Accident that occurred on:
Physician / Other Practitioner Certification
(Month / Day / Year)
I certify the above person was or is unable to perform his or her duties
during the period indicated above due to illness or injury.
B. ABSENCE CERTIFICATION/ REQUEST
☐ Family Medical Leave (FMLA) (c
heck one below):
☐ V
acation ☐ Illness ☐ Unpaid
☐
Personal Necessity: Indicate reason:
Signature of Licensed Physician/Other Practitioner
Date
☐
1. Personal Business
☐
2. Qualifying Event [Local 99 Only]
☐
3. Death of immediate family member.
☐
4. Accident involving my person.
☐
5. Accident involving:
☐
a. My Property
☐
b. Person or property of a member of my immediate family.
☐
6. Appearance in court as litigant.
☐
7. Appearance as witness under governmental order
☐
8. Illness of member of immediate family.
☐
9. Birth of child – partner/domestic partner.
☐
10. Imminent danger to my home.
☐
11. The following significant event which required my attention during my regular assigned working hours:
Reason
☐
Bereavement
Out of State Travel Required?
Relationship
Date of Death
(Month/Day/Year)
☐
No
☐
Yes
C.
A
BSENCE
R
EQUEST
:
I request to be absent from my position during the absence period indicated above due to:
E
MPLOYEE
:
A
LL
☐ Court Subpoena (Witness)
☐ Governmental Order
☐ Jury Duty
☐ Unpaid
☐ Work-Related
E
MPLOYEE
:
A
DMINISTRATOR
☐ Organization
☐ Wellness Day [Teamsters Only]
☐ Vacation
E
MPLOYEE
:
F
ACULTY
☐ Compensatory Time Taken
☐ Conference / Meeting
☐ Floating Vacation Day [“D”-Basis Only]
☐ Maternity / Paternity
☐ Non-Duty [“D” Basis Only]
☐ Personal Annual Leave (PAL)
E
MPLOYEE
:
C
LASSIFIED
☐
Annual Eye Exam – Requires supplemental Physician’s Certification form.
☐
Annual Physical - Requires supplemental Physician’s Certification form
☐ Parental [AFT 1521A only]
☐ Substitute Holiday for ________________
☐ Union Activities
____________________
☐ Vacation
☐ Vacation in Lieu of Illness
☐
Casual Absence
☐ Compensatory Time Taken
☐
Non-Duty [“G” Basis Only]
☐ Organization
☐ Personal Annual Leave (PAL)
[AFT 1521A & Local 721]
☐ Other (Specify):
D.
SUPERVISOR’S REPORT OF EMPLOYEE ABSENCE:
☐Absence Without Leave ☐ Unpaid Tardy
☐ Paid Tardy - AFT 1521A only
3.
SIGNATURES:
Employee
LACCD Form TA-1 05/12/2017
Date
Supervisor
Date
Print Form
LACCD Form TA-1 (Side 2) 05/12/2017
ABSENCE CERTIFICATION / REQUEST DEFINITIONS
ITEM
DEFINITION
S
ERVICE
:
Academic: Employees having responsibility for the operation of or formulating policy for the instructional or student services program (California
Code of Regulations, Title 5 § 53402; LACCD Board Rule 10301).
Classified: Every position not defined by the regulations of the board of governors as an academic position and not specifically exempted from the
classified service according to the provisions of Section 88003 (California Educational Code § 88004; Personnel Commission Rule 516
Classification Plan)
2A: ABSENCE CERTIFICATION: Absences of this nature are normally unanticipated. Absences of this nature require certification.
Illness or Injury
Self-Explanatory.
2B: ABSENCE CERTIFICATION/ REQUEST: Absences of this nature can be either unanticipated events or absences scheduled in advance.
FMLA
FMLA entitles eligible employees of covered employers to take unpaid, job-protected leave for specified family and medical reasons. This is for an
absence for intermittent FMLA that has already been processed. At LACCD, FMLA can be Paid or Unpaid. If the employee is taking Paid FMLA, the
employee shall check the one box of the absence type they are applying to their FMLA first; otherwise, if taking Unpaid FMLA, check Unpaid.
Personal Necessity
Is paid time granted to permit an employee to be absent without loss of pay when specific conditions or events require the personal attention of the
employee and involve circumstances the employee cannot be reasonably be expected to disregard. See possible list of items on the front side of
the Form TA-1 except for Personal Business and “Qualifying Event” which are explained below.
Personal Business
Per the number of days specified in the particular collective bargaining agreements (AFT 1521A, Crafts, Local 721, Local 99), the employee may
use Personal Necessity days for personal business, as long as the employee notifies the supervisor in writing ahead of the absence in accordance
with the specific collective bargaining agreements.
Qualifying Event
(Local 99 Only)
For Local 99 employees only, one day in accordance with the collective bargaining unit, shall be available for any reason, chargeable to illness. If
unused, such day shall not accumulate from year to year.
Bereavement
For the death of an immediate family member. See the applicable Board Rule or collective bargaining agreement for further definitions and
pertinent occasions.
2C: ABSENCE REQUEST: Events or absences scheduled in advance. Absences of this nature are requested.
EMPLOYEE: ALL
Court Subpoena (Witness)
Granted to an employee for the actual time he or she needs to comply with a subpoena to appear as a witness. (See HR Guide P-407).
Governmental Order
Employee to appear as a witness in court, other than as a litigant, or to respond to an official order from another governmental jurisdiction for
reasons not brought about through misconduct or connivance on the part of the employee (See HR Guide P-407).
Jury Duty
Granted to an employee for the actual time he or she needs to comply with a summons for jury duty (See HR Guide P-407).
Unpaid
After all vacation or illness days are exhausted, an employee may take a day without compensation in accordance with the particular Board Rule or
the applicable collective bargaining agreement.
Work-Related
Employees may participate in examinations and other employment procedures and employee may be paid their regular salary for anytime they are
unable to work at their place of employment because it is closed due to epidemic or emergencies. The specific details and items the employee is
eligible for are listed in the applicable Board Rules or the specific collective bargaining agreement of the unit the employee belongs too.
EMPLOYEE: ADMINISTRATOR
Organization
An organization leave is a leave which is granted to enable an employee to serve as an elected officer of any local community college district public
employee organization, or of any statewide or national public employee organization with which the local organization is affiliated. See individual
bargaining unit contracts for additional definitions. See Education Code Sections 87768.5 and 88210.
Wellness Day
[Teamsters Only]
One (1) day granted each fiscal year to only the Teamsters; Unit member shall give supervisor a minimum 2 days prior written notice; If not used in
fiscal year, day shall not carry forward.
Vacation
The number of days or hours per year for which an employer agrees to pay workers, for other than illness, while they are not working. See the
Board Rules or the specific contractual bargaining agreement for accrual rates.
EMPLOYEE: FACULTY
Compensatory Time
Taken
Any non-classroom faculty member who agrees to work in accordance with the collective bargaining agreement during a holiday, vacation day that
is not part of their assignment basis will be allowed compensatory time off after the service is rendered.
Conference / Meeting
A faculty member may in certain cases be paid to conferences/meetings. See the collective bargaining agreement for all applicable instances.
Floating Holiday
[“D”-Basis Only]
All full-time employees assigned to non-classroom teaching duties may elect, subject to the approval of the college president or vice chancellor, to
take vacation days at a time other than when the vacation day is scheduled. These vacation days must be taken during the period of time such an
employee is normally assigned.
Maternity / Paternity
Leave of absence for any contract or regular faculty member who is required to absent herself or himself form their duties due to the birth or
impending birth of a child or arrival of an adopted child.
Non-Duty [“D” basis Only]
“D” Basis assignments paid over 12 months are based on a total of 240 duty days to be worked between July 1 and June 30 and a pre-determined
number of unpaid days to be taken off each year; such unpaid days are reported as non-duty days.
Personal Annual Leave
(PAL)
Up to one day per year, designated for a significant event, shall be available to the faculty member without being deducted from the number of full
pay days allocated to the faculty member; if unused, such day shall not accumulate from year to year.
EMPLOYEE: CLASSIFIED
Annual Eye Exam
This must be completed prior to the exam. Upon returning from the exam, a completed Physician’s Certification (LACCD Form P-402) must be
submitted. See form P-402 for the applicable units and the amount of time allocated for the exam.
Annual Physical
This must be completed prior to the exam. Upon returning from the exam, a completed Physician’s Certification (LACCD Form P-402) must be
submitted. See form P-402 for the applicable units and the amount of time allocated for the exam.
Casual Absence
Casual Absence is excused paid absence when good reason for such absence exists and may be denied by the supervisor if the work of the unit is
materially retarded.
Compensatory Time
Taken
Overtime is compensated as either a cash payment or compensatory time off in accordance with the applicable Board Rule of collective bargaining
agreement. If compensatory time is taken, the employee must abide by the applicable Board Rule of collective bargaining agreement.
Non-Duty [“G” Basis Only]
“G” Basis assignments paid over 12 months are based on a total of 239 duty days to be worked between July 1 and June 30 and a pre-determined
number of unpaid days to be taken off each year; such unpaid days are reported as non-duty days.
Organization
An organization leave is a leave which is granted to enable an employee to serve as an elected officer of any local
community college district public employee organization, or of any statewide or national public employee organization with which the local
organization is affiliated. See individual bargaining unit contracts for additional definitions. See Education Code Sections 87768.5 and 88210.
Personal Annual Leave
(PAL) [1521A & 721]
In accordance with the AFT 1521A and Local 721 collective bargaining agreements, one day may be available to the employee with being
deducted from the number of full-pay days allocated to Personal Necessity. If unused, such day shall not accumulate from year to year.
Parental [1521A only]
Mandatory leave granted to an employee due to the birth of his/her own child or the arrival of a his/her own adopted child.
Substitute Holiday
In certain instances in accordance with the specific collective bargaining agreements, an employee may take a day off identified in place of the
holiday if the supervisor agrees to the plan.
Union Activities
In accordance with the particular collective bargaining agreements union release time may be granted in one of the five occasions below:
Meetings/Conferences (Time Code 1830), Fixed allocation union release time (Time Code 1845), Negotiation release time (Time Code 1850),
Representation activities (Time Code 1860), Participatory Governance (Time Code 1865). Enter the type of activities on the associated line.
Vacation
The number of days or hours per year for which an employer agrees to pay workers, for other than illness, while they are not working. See the
Board Rules or the specific contractual bargaining agreement for accrual rates.
Vacation in Lieu of Illness
When a permanent employee has exhausted his/her full-pay illness credit, he/she shall, at his/her request be allowed vacation in lieu of half-pay
illness. The number of days paid as vacation may not exceed the employee’s vacation allowance.
OTHER (SPECIFY)
This line is for other approved absences that are not specifically listed on the reverse side of the form, such as short term military leaves.
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Form 1.: 770 WILSHIRE BOULEVARD AM (Los Angeles Southwest College)

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Completed 25 July 2020

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