Fillable Leave Request (NOT Requiring ERSC Authorization) (Montgomery Schools)

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Leave Request (NOT Requiring ERSC Authorization) (Montgomery Schools)

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MCPS Form 430-1A
September 2020
Leave Request (NOT Requiring ERSC Authorization)
Employee and Retiree Service Center (ERSC)
MONTGOMERY COUNTY PUBLIC SCHOOLS • Rockville, Maryland 20855
0 0 0
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 □ Sick Leave □ 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
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.
ADDITIONAL INFORMATION: For further information refer to the appropriate agreements:
Agreement between Montgomery County Education Association and Board of Education of Montgomery County, Rockville, Maryland
Agreement between Montgomery County Association of Administrators and Principals (MCAAP and MCBOA) and Board of Education of
Montgomery County, Rockville, Maryland
Agreement between SEIU Local 500 and Board of Education of Montgomery County, Rockville, Maryland
FAMILY AND MEDICAL LEAVE ACT (FMLA):
Sick Leave and Illness in Family leave may be covered by the Family and Medical Leave Act (FMLA) and, as such, may be counted against
your twelve (12) work-week FMLA entitlement. The FMLA covers leave for the birth and care of an employee’s newborn child, for place-
ment with the employee of a child for adoption or foster care, to care for an immediate family member with a serious health condition, or
for an employee’s own serious health condition.
Leave will be without pay unless the employee’s annual and/or sick leave is allowable under the Agreement. Employees using paid sick
leave not in accordance with the Agreement will be required to reimburse MCPS.
TYPES OF LEAVE
Annual*
Personal*
Sick Leave**
Illness in Family**
Family Bereavement—Specify relationship and date of death.
Civil, Juror, or Witness—Not applicable when employee is plaintiff or defendant. Attach a copy of subpoena.
**Cannot be approved if sufficient leave is not available.
** All hours of available leave will be applied.
READ CAREFULLY BEFORE SIGNING REVERSE SIDE:
I have earned or been advanced leave in the amount requested. I understand that I will be required to repay any monies received for leave
taken in excess of that earned if I resign before the end of the fiscal year for which leave is advanced.
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Leave Request (NOT Requiring ERSC Authorization) (Montgomery Schools)

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Completed 21 May 2021

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