Common use of Requested Leave Clause in Contracts

Requested Leave. (Last Working Date) (Expected Date of Return) Approved Not Approved OFFICE OF HUMAN RESOURCES RE-1J Approved Not Approved (Signature) (Date) (Board President) (Date) I, , understand that I am eligible to continue my District health insurance, at my expense, for up to one year, while on authorized leave with Montrose County School District. I understand monthly premiums must be paid by the 15th of each month or coverage will be cancelled. No further notice for premium payment will be sent. I ELECT to continue coverage (at my expense) I ELECT NOT to continue coverage Signature Date HR Department Representative Date Payroll Department Representative Date Last Name First Middle Employee ID # (from HR) Mailing Address City State Zip Code Assigned Site (School)/ Position Telephone Number (Home/Cell) Telephone Number Name Business Address Business Phone Name Business Address Business Phone I have days of leave. (Note: Leave days are the total days already accumulated and those that will accrue throughout the current contract year.) I am applying to the Catastrophic Leave Bank for number of days. My signature below constitutes my acknowledgement and permission for the Catastrophic Leave Bank Committee to obtain the health care information they need from my physician(s) in order to process my request for days from the Catastrophic Leave Bank. I understand that I may revoke this Authorization in writing at any time. However, my revocation will not apply to information already supplied by my physician(s) to the Committee. Unless I revoke my authorization in writing, this Authorization shall automatically expire 3 months from the date of my signature below. Start Date of Requested Leave: Expected Date of Return: Please check one box: ESP Licensed Name of Patient and Relationship to Employee Medical Diagnosis I certify that has been under my treatment and care and that this illness/injury, quarantine or non-elective surgery is such that it renders the employee unable to perform his/her work duties on a temporary basis or creates the medical need of assistance by employee. This employee needs approximately ▇▇▇▇ to attend to his or her spouse/child/legal dependent or to recuperate and return to his or her assigned duties. Date Physician’s Signature Date Physician’s Signature Action Approved Not Approved Date Reason: Effective Date of Use: Termination of Use: Days Charged to Bank: Signature of CLB Member Signature of Human Resource Representative

Requested Leave. (Last Working Date) (Expected Date of Return) Approved Not Approved OFFICE OF HUMAN RESOURCES RE-1J Approved Not Approved (Signature) (Date) (Board President) (Date) I, , understand that I am eligible to continue my District health insurance, at my expense, for up to one year, while on authorized leave with Montrose County School District. I understand monthly premiums must be paid by the 15th of each month or coverage will be cancelled. No further notice for premium payment will be sent. I ELECT to continue coverage (at my expense) I ELECT NOT to continue coverage Signature Date HR Department Representative Date Payroll Department Representative Date Last Name First Middle Employee ID # (from HR) Mailing Address City State Zip Code Assigned Site (School)/ Position Telephone Number (Home/Cell) Telephone Number Name Business Address Business Phone Name Business Address Business Phone I have days of leave. (Note: Leave days are the total days already accumulated and those that will accrue throughout the current contract year.) I am applying to the Catastrophic Leave Bank for number of days. My signature below constitutes my acknowledgement and permission for the Catastrophic Leave Bank Committee to obtain the health care information they need from my physician(s) in order to process my request for days from the Catastrophic Leave Bank. I understand that I may revoke this Authorization in writing at any time. However, my revocation will not apply to information already supplied by my physician(s) to the Committee. Unless I revoke my authorization in writing, this Authorization shall automatically expire 3 months from the date of my signature below. Start Date of Requested Leave: Expected Date of Return: Please check one box: ESP Licensed Name of Patient and Relationship to Employee Medical Diagnosis I certify that has been under my treatment and care and that this illness/injury, quarantine or non-elective surgery is such that it renders the employee unable to perform his/her work duties on a temporary basis or creates the medical need of assistance by employee. This employee needs approximately ▇▇▇▇ to attend to his or her spouse/child/legal dependent or to recuperate and return to his or her assigned duties. Date Physician’s Signature Date Physician’s Signature Action Approved Not Approved Date Reason: Effective Date of Use: Termination of Use: Days Charged to Bank: Signature of CLB Member Signature of Human Resource Representative