EMPLOYEE NAME: (LAST, FIRST, MIDDLE) BARGAINING UNIT EMPLOYEE ID #
CLASSIFIED
ACADEMIC
LOCATION NO. LOCATION NAME: POSITION TITLE:
START DATE END DATE NO. OF DAYS NO. OF HOURS TIME (FROM – TO)
Type of Leave [check appropriate box] and provide details as indicated. Only the employee should complete the form.
Any changes should be initialed by the employee.
Vacation
Change to previously submitted request? Y N
Previous Dates:
Sick Leave** (may need verification from physician)
Faculty Monthly Faculty Hourly
Family Necessity Leave** Care for unit member's sick child, parent, spouse or domestic partner.
Leave, per calendar year, taken from Accrued, Full Salary Sick Leave only.
Personal Necessity Leave ** (may qualify for FMLA depending on circumstances)
Leave, per fiscal year, taken from Accrued, Full Salary Sick Leave only.
Comments/Reasons:
Relationship:
Reason (if required by agreement)
Comp Time
Available balance Remaining Balance
(for office use only)
SHORT-TERM LEAVE (NOT TO EXCEED 30 CALENDAR DAYS)
(paid, unless otherwise indicated)
Personal Business w/Pay
Personal Business w/out Pay** (may qualify for FMLA depending on circumstances)
Adoption/Paternity/Parental Leave **
w/pay (One day paid leave)
w/out pay (not to exceed 30 days)
Bereavement Leave -- (indicate # of travel miles
)
Short-Term Military Leave (not to exceed 30 workdays)
Court Appearance (other than litigant)
Jury Duty
Comments/Reasons:
Relationship:
Attach Orders
Attach supporting documents
LONG-TERM LEAVE (In excess of 30 CALENDAR DAYS)
(unpaid unless otherwise indicated)
Health Leaves - including leave due to pregnancy**
Family/Parental ** ( not qualifying for FMLA/CFRA)
Professional Study Leave
Service to Other Public Agencies & Institutions
Long-Term Military Leave - more than 30 workdays per college year (First 30 days paid)
Other (specify reason) - at Chancellor's discretion
Comments/Reasons:
Relationship:
Attach Materials Outlined in Agreement
Attach Orders
Specify reasons:
OTHER LEAVE OF ABSENCE
On The Job Injury/Industrial Accident **(requires physician's signature below)
Employee Organization Leave
Union-Paid Release Time
District Off-site Activity (District interviews, workshops, staff development meetings)
Date of Injury:
Name of Organization:
Identify Union:
Identify District Activity:
GENERAL INFORMATION – FMLA/CFRA
Family Medical Leave Act (FMLA)/California Family Rights Act (CFRA) **
• Birth of a child/Care of newborn Date of Birth
• Care for employee's parent, child, spouse or domestic partner
• Adoption, placement or Foster care (with employee) Date of Adoption
• Serious health condition of employee (Note: CFRA does not include pregnancy or related medical conditions within
definition of serious health condition.)
GENERAL INFORMATION – FMLA/PDL
Family Medical Leave Act (FMLA)/Pregnancy Disability Leave
(PDL)**
• Pregnancy that makes absence from work medically necessary
Physician’s Certification: I certify that the above named person was unable to work during the above period.
PHYSICIAN’S SIGNATURE LICENSE NO. DATE
REQUEST FOR LEAVE OF ABSENCE
SAN DIEGO COMMUNITY COLLEGE DISTRICT
INSTRUCTIONS: PLEASE PREPARE ONE COPY AND SUBMIT TO YOUR SUPERVISOR AND/OR MANAGER FOR CONSIDERATION.
IMPORTANT: NOT ALL LEAVES ARE AVAILABLE TO ALL EMPLOYEES
REFER TO APPROPRIATE BARGAINING AGREEMENT/HANDBOOK FOR INSTRUCTIONS AND REGULATIONS
**NOTIFICATION: THIS LEAVE CONSTITUTES NOTIFICATION FOR FMLA AND/OR CFRA QUALIFYING EVENTS, PROVIDED THE EMPLOYEE IS QUALIFIED. PLEASE BE ADVISED THAT THE
LEAVE WILL RUN CONCURRENTLY WITH ANY AVAILABLE FMLA AND/OR CFRA LEAVE. SEE REVERSE FOR QUALIFYING REQUIREMENTS.
EMPLOYEE’S SIGNATURE DATE MANAGER’S/SUPERVISOR’S SIGNATURE DATE
(Please read the notice on page two of this form)
(For Long-term Unpaid Leave of Absence for “Other”) CHANCELLOR’S SIGNATURE DATE
Distribution: ORIGINAL: TIMEKEEPER PHOTOCOPY: SUPERVISOR PHOTOCOPY: EMPLOYEE
RQABS-Page 1 Feb. 29, 2008
