REQUEST FOR LEAVE
REGULAR/SALARIED EMPLOYEES AND
PART-TIME, HOURLY CREDIT FACULTY
NAME: EMPLOYEE ID#:
The hours of absence will be deducted from salary 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 category definitions.
DEDUCTIBLE FROM LEAVE
Date(s) and Hours
Total # of Hours
Sick Leave (not related to an industrial injury/illness)
Deducted from sick leave:
Personal Necessity
Protected Sick Leave (Kin Care)
Emergency Paid Sick Leave Act
Parental Leave
Leave to Appear at Child’s School
Qualifying reason:
Military Leave
Vacation (not applicable for faculty)
Personal Business
(not applicable for part-time faculty)
Faculty Only - Provide name of substitute:
Comp Time
FACULTY ONLYAbsence was from: regular contract hours overload hours
NON-DEDUCTIBLE FROM LEAVE
Date(s) and Hours
Total # of Hours
Bereavement:
List relationship:
Jury Duty and Witness Leave (attach proof of services)
Assigned Napa Valley College Activity/Conference
*Industrial Injury/Illness
(Workers’ Compensation)
*Signature of Risk Management Office Representative
_________________
Date
Reason
Date(s) and Hours
Total # of Hours
Signature of Employee Date
In accordance with Board policy, administrative regulations, and negotiated contracts, this leave request should be granted.
Signature of Supervisor Date
PLEASE SUBMIT TO THE OFFICE OF HUMAN RESOURCES, TRAINING & DEVELOPMENT
Office of Human Resources, Training & Development
CLEAR FORM
PRINT FORM
PRINT FORM
CLEAR FORM
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signature
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signature
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signature
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PERSONAL ILLNESS OR INJURY LEAVE (SICK LEAVE)
In case of illness or other emergency, your supervisor should be notified as soon as possible. All employees should submit a leave
slip with physician’s statement attached for any planned illness or injury absences in excess of one week.
All Employees:
A physician’s statement must be filed for any sick leave in excess of five days, no later than five days after returning from leave.
Faculty:
A contract/regular (tenure-track/tenured) faculty unit member who is absent for a full day, shall have a full day deducted from
his/her accumulated leave and a contract/regular faculty member who works for only a portion of his/her scheduled work day
shall have one-half day deducted from his/her accumulated leave.
Part-time, hourly credit and noncredit faculty and overload assignments earn one hour of sick leave for every 17.5 hours of
teaching, counseling, or librarian work. Leave is deducted on an hour-for-hour basis.
PERSONAL NECESSITY (DEDUCTED FROM SICK LEAVE)
Acceptable uses of personal necessity leave are outlined in employee labor agreements and district policy. The reason for this
absence must be stated on the absence form.
Contract/Regular Faculty, Administrative/Confidential: Maximum of six days per fiscal year. Classified: Maximum of six days per
fiscal year. Part-Time, Hourly Credit Instructors: Maximum of 6 hours per semester.
PROTECTED SICK LEAVE (KIN CARE - DEDUCTED FROM SICK LEAVE)
Applies to absences due to medical appointments for and/or an illness of a child, parent, spouse, or registered domestic partner of
the employee. The reason for this absence must be stated on the absence form.
Contract/Regular Faculty: Maximum of five days per academic year. Administrative/Confidential and Classified: Maximum of six days
per fiscal year. Part-Time, Hourly Credit and Noncredit Instructors: Maximum 6 hours per semester.
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. A full-time employee may take up to two weeks (or 80
hours) of paid sick leave or 2/3 of the employee's regular rate of pay in a two work week period (subject to limitations) for any
combination of qualifying reasons. Employees may supplement the 2/3 with accrued sick leave. Certification required for qualified
reason.
PARENTAL LEAVE (DEDUCTED FROM SICK LEAVE)
Up to twelve work weeks for reason of the birth of a child of the employee, or the placement of a child with an employee in
connection with the adoption or foster care of the child by the employee.
LEAVE TO APPEAR AT CHILD’S SCHOOL (DEDUCTED FROM SICK LEAVE)
For school activities, up to 40 hours per year, but not to exceed more than eight hours in one calendar month. For school
suspensions, there is no limit.
PERSONAL BUSINESS DAYS
Contract/Regular Faculty: One day per semester, not charged to personal illness and injury leave. The unit member shall reimburse
the District for the actual cost of a substitute. The unit member must give the District five working days notice.
Administrative/Confidential and Classified: Two days (16 hours) per year, not charged to personal illness and injury leave.
The employee must give the District three working days notice. The leave may be taken in increments of one hour.
BEREAVEMENT LEAVE
Death of any member of immediate family (see definition below). Up to one day allowed to attend the funeral of a close relative or
in-law.
Faculty: Up to three days, or five days if travel in excess of 300 miles one way is required. Administrative/Confidential and Classified:
Up to five days.
INDUSTRIAL INJURY/ILLNESS (WORKER’S COMPENSATION) OR INDUSTRIAL INJURY/ILLNESS-RELATED DOCTOR’S APPOINTMENT
Leave is not charged to personal injury or illness leave (sick leave). To qualify, employee must complete (or have already completed)
a Worker’s Compensation Claim Form (DWC Form 1) and submit it to Risk Management. Leave is subject to review by W/C insurance
carrier and any lost time related to a claim that is rejected will be charged to personal sick leave.
The above summarizes language from employee labor agreements and district policy to aid employees in completing the Request
for Leave form. Nothing listed above shall supersede actual employee labor agreements and district policy. Less-than-full-time
and less-than-twelve-month employees have their Personnel Necessity, Protected Sick Leave, and Personal Business Leave prorated
accordingly.
Rev.2/2006, 11/2006, 4/2008, 2/2013, 8/2014, 10/2018, 12/2019, 4/2020
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