MCPS Form 430-1A
December 2017
MCPS Form 430-1A
December 2017
Leave Request (NOT Requiring ERSC Authorization)
Employee and Retiree Service Center (ERSC)
MONTGOMERY COUNTY PUBLIC SCHOOLS • Rockville, Maryland 20855
Leave Request (NOT Requiring ERSC Authorization)
Employee and Retiree Service Center (ERSC)
MONTGOMERY COUNTY PUBLIC SCHOOLS • Rockville, Maryland 20855
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Name
Last First MI Employee No.
Number of Days (or) Hours Expected Dates of Leave / / through / /
Half day or less □ A.M. □ P.M.
School/Location Name
Job Title (if teacher, subject/grade) Phone(s) - - , - -
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Name
Last First MI Employee No.
Number of Days (or) Hours Expected Dates of Leave / / through / /
Half day or less □ A.M. □ P.M.
School/Location Name
Job Title (if teacher, subject/grade) Phone(s) - - , - -
CHECK TYPE OF LEAVE (See reverse side for explanation, requirements, and Family and Medical Leave Act information)
□ Annual □ Personal □ Personal Illness □ Illness in Family □ Family Bereavement
Additional Documentation Required □ Civil, Juror, or Witness □ Military Training □ Workers’ Compensation
Specify details as appropriate
CHECK TYPE OF LEAVE (See reverse side for explanation, requirements, and Family and Medical Leave Act information)
□ Annual □ Personal □ Personal Illness □ Illness in Family □ Family Bereavement
Additional Documentation Required □ Civil, Juror, or Witness □ Military Training □ Workers’ Compensation
Specify details as appropriate
Read reverse side carefully before signing: / /
Signature, Employee Date
Read reverse side carefully before signing: / /
Signature, Employee Date
AUTHORIZATION
□ Approved [Substitute Required? □ Yes □ No □ Not Approved (give reason) ___________________________________________________________
/ /
Signature, Principal/Director/Supervisor Date
□ Approved □ Not Approved (give reason)
/ /
Signature, Deputy/Assoc. Superintendent/Designee Date
AUTHORIZATION
□ Approved [Substitute Required? □ Yes □ No □ Not Approved (give reason) ___________________________________________________________
/ /
Signature, Principal/Director/Supervisor Date
□ Approved □ Not Approved (give reason)
/ /
Signature, Deputy/Assoc. Superintendent/Designee Date
INSTRUCTION: To be completed when an employee is requesting annual or personal leave for any number of days/hours, bereavement leave for 5 days or
fewer, or all other types of leave for 4 days or fewer. Leave requests not meeting these criteria should be submitted on MCPS Form 430-1. Attach copies of
appropriate documentation and submit to your principal/director/supervisor. Approved form must be attached to employee’s timesheet. Refer to reverse
side for detailed instructions.
INSTRUCTION: To be completed when an employee is requesting annual or personal leave for any number of days/hours, bereavement leave for 5 days or
fewer, or all other types of leave for 4 days or fewer. Leave requests not meeting these criteria should be submitted on MCPS Form 430-1. Attach copies of
appropriate documentation and submit to your principal/director/supervisor. Approved form must be attached to employee’s timesheet. Refer to reverse
side for detailed instructions.
