Form No. 60.NON-ILL; Reissued 07/09/2020
N
O
N
I
L
L
N
E
S
S
Los Angeles Unified School District
CERTIFICATION AND/OR REQUEST OF ABSENCE FOR NON-ILLNESS
EMPLOY
EE INFORMATION (Please Print)
Last Name
First Name
M.I.
Employee No.
Work Location Name
Job Title
Employee’s Telephone
( )
REASON FOR ABSENCE
1. Starting date of absence ______/______/_______ Last date of absence (expected) ______/______/_______
Mo. Day Yr. Mo. Day Yr.
2. Total time (expected) of absence: _____ days; _____ hours.
NOTE: This form does not supersede or replace the Leave of Absence Request Form (PC Form 5006 or HR Form 1065), when
required.
3. Select the appropriate type of absence:
A) Accident or Imminent Danger to My Person/Property (see rule
1
)........................... Explain _______________________________
B) Accident to Family Member’s Property (see rule
1
)………………………….……. Explain _______________________________
C) Auto failure (up to 2 hours) if car used for work on that day (see rule
2
)….….…....
D) Registration or Final Exam in Higher Education (see rule
3
)………………….…....
E) Religious Holiday of My Faith………………………….… Paid Unpaid
F) Court Appearance………………………………………..Paid Unpaid
G) School Activity………………………………………..…… Paid Unpaid
Provide Verification _____________________
H) Bereavement (see rule
4
)……………………………………………………….……
I) Conference Approved by District…………………………………………….…….
J) Jury Duty…………………………………….…..………………………………....
K) Vacation (All regular classified employees & Certificated A basis)………………
Accrued Vacation Hours Requested 1994 Vacation Bank Hours Requested
L) Paid Parental Leave (Birth of a child/Newly adopted/New foster care)…………….
Accrued Vacation Hours Requested 1994 Vacation Bank Hours Requested
M) Other Absences (identify _______________________________)………………...
NOTE: Absences “A” through “G” may qualify as Personal Necessity. Absences “K” and “L” may qualify for FMLA/CFRA.
Additional Explanation, if needed ______________________________________________________________________________________
____
__________________________________________________________________________________________________________________________
I certify I was/will not be employed elsewhere during my regular work hours within the time period claimed on this certification, unless taking
vacation. I certify my absence during this period was not and is not for participating in a strike/work stoppage or because of my unwillingness to
cross picket lines and I would have been available for duty if it had not been for the reason cited above. Furthermore, I certify my absence during
my hours of assigned duty is because of the above listed reason in accordance with any applicable Board/PC rule or Collective Bargaining
Agreement. I also agree and authorize that once the correct benefit usage charged above is processed, any unearned wages paid as a result will
be collected from the next paycheck. I declare under the penalty of perjury that the foregoing is true and correct.
Employee’s Signature ________________________________________________ Date________________________
Is there an FMLA/CFRA/PDL Approved Designation Notice on file that covers this absence? Yes No
Administrator/Supervisor’s Acknowledgment:
____________________________ __________________________________ ________________________________
Print Name Signature Date
For Administrator/Supervisor: Do you approve the requested absence? Yes No
Explanation (If No):_____________________________________________________________________________________________
1
Rule to #3.A or B: Accident to property must be either your property or immediate family member’s (either your family or spouse’s, such as, parent, child, grandparent, grandchild,
brother, sister, step/foster child or other relative living in employee’s immediate household). Reference the specific section of the bargaining unit agreement or any applicable
Board/PC rule if another relationship is claimed. Imminent danger to property includes only your property, and is occasioned by disaster such as flood, fire, or earthquake.
2
Rule to #3.C, F, G: Refer to applicable bargaining unit agreement or any applicable Board/PC rule.
3
Rule to #3.D: Upon at least two days' notice to their immediate supervisor, a classified employee shall be permitted to take any examination and to participate in other District
employment procedures during working hours without loss of pay or other penalty. If less than two days' notice is provided, permission to participate without loss of pay is subject to
approval by the employee’s immediate supervisor. (PC Rule 807)
4
Rule to #3.H: The rule requires that the relationship be an immediate family member meaning under LAUSD’s definition for bereavement. The immediate family is defined as the
parent, grandparent or grandchild of the employee or the employee's spouse, and the spouse, child (including foster child), brother, sister, daughter-in-law, or son-in-law of the
employee, or any relative living in the immediate household of the employee. Reference the specific section of the bargaining agreement or any applicable Board/PC rule for further
information.
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome