Fill and Sign the Denver Public Schools Department of Human Resources Form

Department of Human Resources REQUEST FOR EXTENDED LEAVE OF ABSENCE CLASSIFIED PERSONNEL Name: ______________________________________ Date of request: _____________________________________ Department: _________________________________ Social Security Number: ______________________________ I hereby request a Leave of Absence from :Employee Group: ______________________________________________ (date) ______________________________________ to (date) ________ Type of leave requested as provided in Company Policy or Union Agreement. Association Activities Leave. Article/Policy ________ I wish to return to my present assignment Yes No ACTION Program Leave . Article/Policy ________ I wish to return to my present assignment Yes No Peace Corps Leave . Article/Policy ________ I wish to return to my present assignment Yes No Military Leave . I wish to return to my present assignment Yes No Active service in time of war or national emergency or extended active duty. Temporary or active service (up to 15 days) for National Guard or any component of United States or state reserve forces. Health . Contact Employee Health Services for appropriate forms. I wish to return to my present assignment Yes No Maternity Leave. Article/Policy ________ Family Illness Leave. Article/Policy ________ Extended Personal Illness Leave. Article/Policy ________ Restoration of Health Leave with half pay . Article/Policy ________ Paternity Leave Health Office Review ________________________________________________________ ___________ Manager, Employment Benefits Date Adoption Leave. Article/Policy ________ I wish to return to my present assignment Yes No Elective Office Leave . Article/Policy ________ I wish to return to my present assignment Yes No General Leave . Article/Policy ________ I wish to return to my present assignment Yes No Leave for Study without pay . Attach complete description of your study plan. ________ One-half year. ________ One year. I wish to return to my present assignment Yes No Mailing address while on leave: _____________________________________ ___________________ ____________________ ____________________ Street City State and Zip Telephone ___________________________________________________________ Signature of Department Supervisor Recommended: ___________________________________________ Director, Human Resources Approved :________________________________________________ Human Resources, Executive Director I.Eligibility . To be eligible for a general leave of absence without pay, an employee must: A. Have completed at least three continuous years of active full time service in the Denver Public Schools just prior to the request for leave. B. State a reasonable condition for extended leave not covered by other leave of absence provisions. II. Application . Applications for general leave of absence must be filed in the Department of Human Resources not later than November 1 or April 1 preceding the semester of the school year for which the leave is requested, except in case of extreme emergency. A. Period of Leave . General leaves of absence will be for one semester or one year. Return from such leave can be only at the beginning of a semester. A general leave of absence may be extended for one year at a time without pay or incre ment for up to five years. B. Return to Employment . Every effort will be made to return an employee to a comparable position upon return from a general leave of absence. C. Seniority . Time spent on a general leave of absence will not be accreditable for seniority purposes. D. Benefits . Employee benefits will not continue during the period of leave. My reason for requesting a general leave is as follows: ______________________________________________________________________ ____________________________________________________________________________________________________________________________________________ I, the undersigned, have read, understand, and agree to abide by all provisions of ___________________’s policy or Agreement that provides for the extended leave of absence I have requested above. _________________________________________________________ Signature of Employee