REQUEST FOR LEAVE
PART-TIME HOURLY NON-ACADEMIC EMPLOYEES
AND STUDENT WORKERS
NAME: ID#:
T
he hours of absence will be deducted from pay if enough leave has not been accumulated to cover the leave taken.
The Payroll Department will deduct the appropriate hours from the next salary warrant.
NOTE: See reverse side for entitlement and usage.
DEDUCTIBLE FROM LEAVE
QUALIFYING USES OF ACCRUED SICK LEAVE UNDER
HEALTHY WORKPLACES/HEALTHY FAMILIES ACT OF 2014, PAID SICK LEAVE LAW
Date(s) and Hours
Total # of Hours
Sick Leave (Self)
Doctor/Dentist Appointment (Self)
(not related to an industrial injury/illness)
Qualifying Uses of Accrued Sick Leave Under
Healthy Workplaces/Healthy Families Act of 2014,
Paid Sick Leave Law (see below)
Qualified Uses of Accrued Sick Leave Under
Emergency Family Medical Leave Expansion Act
and Emergency Paid Sick Leave Act
NON-DEDUCTIBLE FROM LEAVE
Date(s) and Hours
Total # of Hours
Judicial (Jury Duty)
(attach proof of services)
Definition of Family Member: Includes parent, child, spouse, registered domestic partner, parent-in-law, sibling,
grandchild, or grandparent.
Qualifying Reasons for Usage of Accrued Sick Leave:
For diagnosis, care, or treatment of an existing health condition of, or preventative care for, an employee, or for
an
employee’s family member.
For an employee who is a victim of domestic violence, sexual assault, or stalking for the purposes described
below:
To obtain or attempt to obtain any relief, including, but not limited to, a temporary restraining order,
restraining order, or other injunctive relief to help ensure the health, safety, or welfare of the victim or
h
is or her child(ren);
To seek medical attention for injuries;
To obtain services from a domestic violence shelter, program, or rape crisis cente
r
To
obtain psychological counseling;
To participate in safety planning and to take other actions to increase safety from future domestic
violence, sexual assault, or stalking, including temporary or permanent relocation.
Signature of Employee Date
In accordance with administrative regulations and procedures and applicable laws, this leave request should be granted.
Signature of Supervisor Date
PLEASE SUBMIT TO THE OFFICE OF HUMAN RESOURCES, TRAINING & DEVELOPMENT
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QUALIFYING USES OF ACCRUED SICK LEAVE UNDER HEALTHY WORKPLACES/HEALTHY FAMILIES ACT OF 2014, PAID SICK LEAVE LAW
Part-time, hourly non-academic employees (hereinafter referred to as hourly employees) hired under a written Notice of
Assignment, Contract for Services, or Personnel Action Form (PAF) issued by the Office of Human Resources or a Work Clearance for
student workers issued by the Financial Aid/EOPS Office are eligible to accrue and use leave under the California Paid Sick Leave Law.
Entitlement and acceptable uses are outlined below and in detail under the “Procedures for Implementing Healthy
Workplaces/Healthy Families Act of 2014, Paid Sick Leave” (provided at the time of hire).
California Paid Sick Leave Clean-Up Legislation (AB 304) expressly excludes CalPERS retired annuitants from being eligible to receive
paid sick leave.
Entitlement:
An hourly employee may use accrued sick leave beginning on the 90th calendar day of employment after July 1, 2015.
Paid sick leave accrues at the rate of one (1) hour per every thirty (30) hours worked.
The maximum number of sick leave hours an hourly employee can accrue is forty-eight (48) hours or six (6) days, whichever
is greater.
A
ccrued sick leave will be reported monthly on the hourly employee’s monthly pay warrant or pay advice based on work
hours reported to Payroll by the 12th of the month.
Accrued paid sick leave up to a maximum of forty-eight (48) hours or six (6) days, whichever is greater, shall carry over to
the following fiscal year of employment.
Sick leave accrued is not retained once the hourly employee terminates, resigns or otherwise separates from employment,
except as outlined below:
An hourly employee who is rehired within one year of departure date will have accrued paid sick leave reinstated,
minus any previously used leave and may use sick leave without the required 90-day waiting period. Reinstated
accrued leave is limited to forty-eight (48) hours or six (6) days, whichever is greater.
Usage:
Hourly employees must request leave by submitting a timecard to report the previously scheduled hours and a Request for
Leave form simultaneously to the employee’s supervisor.
An hourly employee may use accrued sick leave at a minimum of one (1) hour per absence and one-half (1/2) hour
increments thereafter beginning on the 90th calendar day of employment after July 1, 2015.
The employee will be paid hourly for the sick leave hours based on the employee’s regular rate of pay for the
workweek in which the employee uses sick leave.
An hourly employee may use accrued sick leave for a maximum of twenty-four (24) hours or three (3) days, whichever is
greater, per fiscal year for the purposes stated in the “Procedures for Implementing Healthy Workplaces/Healthy Families
Act of 2014, Paid Sick Leave.”
Leave for these purposes shall be deducted from the employee’s sick leave accrual, and the reason for the absenc
e
mu
st be stated on the absence form.
The District reserves the right to request supporting documentation for any absence for the purposes listed under
“Qualifying Reasons for Usage of Accrued Sick Leave.”
Whenever possible, the hourly employee must contact his/her immediate supervisor as soon as the need to be absent is
known, but in no event less than one-half (1/2) hour prior to the start of the work assignment, except in case of emergency.
The hourly employee will submit the above documentation in advance to notify the supervisor of preschedule
d
a
ppointments or planned long-term absences. For unplanned absences, leave slips are to be submitted to supervisor withi
n
five (5) days of returning from leave.
EMERGENCY PAID SICK LEAVE ACT
Paid sick leave under the Emergency Paid Sick Leave Act may be accessed for employee or employee caring for a household
member for recovery, quarantine, or school/child care closure as a direct result of COVID-19. It is in addition to other leave
provided under Federal, State, or local law, and applicable collective bargaining agreement. Emergency Paid Sick Leave is
equal to the average hours worked over a two week period or 2/3 of the employee’s regular rate of pay (subject to
limitations). Employees may supplement the 2/3 with accrued sick leave. Certification required for qualified reason.
JUDICIAL LEAVE
An hourly employee will be provided paid leave for regularly called jury duty and to appear as a witness in court, other than as a
litigant, for reasons not brought about through the connivance or misconduct of the employee. If possible, the employee shall
submit necessary documentation to support the absence no less than ten (10) days prior to the beginning date of the leave or
appearance as a witness.
The employee, while serving jury duty, will receive his/her regular rate of pay for the position from which he/she was absent and
must endorse to the District any stipend received for jury service or inform the Payroll Office in writing of any stipend received. If the
employee fails to endorse to the District any stipend received for jury service, the District shall deduct from the employee’s pay
warrant the amount of such stipend actually paid to and retained by the employee.
Rev.6/2015; 8/2015; 10/2015; 12/2019; 4/2020
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