Fillable NonMedicalLeaveApplication 2014 CALIFORNIA STATE UNIVERSITY, FRESNO

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NonMedicalLeaveApplication 2014 CALIFORNIA STATE UNIVERSITY, FRESNO

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CALIFORNIA STATE UNIVERSITY, FRESNO
Request for NON-MEDICAL LEAVE OF ABSENCE for STAFF and MPP
1. Contact Human Resources (HR) for an appointment to discuss benefits, accruals, and employment status.
2. The request for leave of absence must be reviewed and signed off by the appropriate administrator.
3. Final approval/disapproval of leave request is made by the$VVRFLDWH9LFH3UHVLGHQWRI+XPDQ5HVRXUFHV
PLEASE SUBMIT THIS FORM AT LEAST 30 DAYS BEFORE THE START DATE OF THE LEAVE.
Employee Name Fresno State ID#
Home Address CB
A
/
Non-Rep. Unit
Department
Manager/Admin.
City/State/Zip
Home/Cell
Office phone
HR Contact & Ext.
Proposed Start Date
A
pproved Start Date
Proposed Return/End Date
A
pproved Return/End Date
A. TYPE OF LEAVE REQUEST INITIAL REQUEST EXTENSION
Unpaid Combination of paid and unpaid
Full-time:__________
Partial leave from _____hrs. wk. to ______hrs. wk.
Will you be working an
“Alternate” Work Schedule?
Yes
No
B. LEAVE REQUESTED (Requires Additional Documentation)
Personal Leave: Reason (Attach a brief explanation for leave request)
Professional Development/ Educational (Attach brief explanation of development plan and projected outcomes)
Military Leave (Attach orders) If applicable, please skip section C - Leave Accrual Status.
C. LEAVE ACCRUAL STATUS: PLEASE READ AND INITIAL
If leave is approved with usage of my leave credits, credits will be used until exhausted. After applicable leave credits are exhausted, no
compensation will be paid.
Request to exhaust the following leave credits prior to unpaid leave:
Yes No
Requires Approval of Appropriate Administrator.
V
acation Accruals
Request requires approval of appropriate Administrator.
8_____________________ Approved Denied
CTO/HC credits
Request requires approval of appropriate Administrator. 8_____________________ Approved
Denied
Personal Holiday
Request requires approval of appropriate Administrator. 8_____________________ Approved
Denied
D. SIGNATURES AND APPROVALS
9 If leave of absence is approved, my compensation will be determined by the type of leave.
HJYDFDWLRQSHUVRQDOKROLGD\ as approved in section C
9
My
leave is governed by the CSU Collective Bargaining Agreement, Title V or Confidential Guidelines.
9
If leave of absence is due to personal or professional reasons, I cannot
return before my approved leave end date
without advance
written approval from the $VVRFLDWH9LFH3UHVLGHQWRI Human Resources
9
My health benefits, service credit, leave accruals, or seniority points may be affected by this requested leave of absence (contact
Human Resources and Payroll Services for more details).
I understand and agree to the above leave information.
Employee Signature: ___________________________________ Date______________
yPERSONAL & PROFESSIONAL DEVELOPMENT/EDUCATIONAL LEAVES please check the appropriate box below with
recommendation. Please sign
and forward to HR. y MILITARY Leave, please sign and forward to HR (no recommendation required).
Recommend Approval
Recommend Approval
Do Not Recommend Approval D e an/Appropriate Administrator ______________________ Date__________
Employee and Administrator will be notified of leave status after the Assoc. Vice President of HR has reviewed this request.
Assoc. Vice President of HR
Approved
Denied
HR Analyst:________________ Process & ForPUHYLHZHGZ(PSOR\HH
Reviewed by +5 Manager%HQHILWV
PLEASE RETURN TO:
Human Resources
5150 N. Maple Ave.
Room 1M/S JA41
Fresno, CA 93740-8026
Phone: 559-278-2032
FA
X: 559-278-4275
Revised 6/17/14
cannot
Denied
Approved
Denied Denied
'LUHFW3D\%HQHILWV
9
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Work schedule:________________________
Paid
Do Not Recommend Approval Dept. Chair/ Manager ______________________________ Date__________
Employee’s Responsibility
• Complete the request form for the non-medical leave of absence within the time frame allowed per the Collective Bargaining Unit or
non-represented guidelines. Normally 30 days before leave begins.
• Schedule an appointment to meet with a Human Resources Representative to discuss leave options and benefits.
• Leave of Absence must be approved by the Assoc. Vice President of Human Resources PRIOR to commencing the leave.
• Contact your Department and Human Resources prior to returning to work.
• A letter will be sent to you and your Department regarding the approval or disapproval of your request.
* * * * * * * * * *
• If you are requesting to return sooner than the original leave end date, you must submit a letter to the
Assoc. Vice President of Human Resources requesting an earlier reinstatement PRIOR to returning to work.
• Please note: You cannot return to work unless the request has been approved by the Assoc. Vice President of Human Resources
•
A letter will be sent to you and your Department regarding the approval or disapproval of reinstating earlier.
• Once reinstated from a leave of absence, please check your first pay warrant to ensure all health benefits are reflected.
Human Resources’ Responsibility
• Meet with the employee to discuss leave options and benefits.
• A letter will be sent to the employee and the Department regarding the approval or disapproval of the leave of absence per the
Collective Bargaining Unit.
• Once the leave of absence is due to end, Human Resources will follow-up with the employee and the Department as needed.
Department’s Responsibility
• If an employee requests a non-medical leave, have the employee complete the request for a non-medical leave of absence form.
• Refer employee to Human Resources to discuss leave options and benefits.
• The request must be approved by the Assoc. VP of Human Resources PRIOR to the employee commencing their leave.
• A letter will be sent to the employee and Department regarding the approval or disapprova
l of their request.
* * * * * * * * * *
• If the employee is requesting to return sooner than the original leave end date, the employee must submit a letter to the Assoc.
Vice President of Human Resources requesting an earlier reinstatement PRIOR to returning to work.
• Please note: The employee cannot return to work unless the request has been approved by the Assoc. VP of Human Resources.
•
A letter will be sent to the employee and Department regarding the approval or disapproval of their request
to reinstate earlier.
Effects of a Leave of Absence
The Leave of Absence may
affect:
• required probationary period
• salary bonus programs
• service toward sick leave and vacation accrual
• accumulation of seniority points
• State service in the California State Retirement System (CalPERS)
• State Service with the University
Contact Human Resour
ces and refer to the appropriate Collective Bargaining Agreement (CBA) regarding possible affects of an approved
full or partial unpaid leave of absence.
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NonMedicalLeaveApplication 2014 CALIFORNIA STATE UNIVERSITY, FRESNO

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Completed 18 April 2020

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