ࡱ> `v_[ 3AUbjbj .rΐΐ  EEEEEYYY8n::4Y"EEEE,\p0!!!!!!!$7$&!uE ",!EEEEA" XEEEE! ! Ez kY !W"0" w'Lw' w'E  !!D "w' : WYTHEVILLE COMMUNITY COLLEGE 1000 East Main Street % Wytheville, VA 24382 APPLICATION FOR LEAVE OF ABSENCE Number of hours leave requested: __ FORMTEXT      ___________________________________________________ (leave must be reported in hours and tenths of an hour-- See Note #1 on reverse side; Nine-month faculty see note below*.) Beginning Ending Date/Time__ FORMTEXT      _______ Date/Time____ FORMTEXT      _______ M/d/yyyy h:mm am/pm M/d/yyyy h:mm am/pm Check the type of leave requested: (see reverse side for explanation of the types of leave) ___ FORMCHECKBOX _____Annual Leave ___ FORMCHECKBOX _____Bone Marrow and Organ Donor ___ FORMCHECKBOX _____Civil and Work Related Leave Reason:  FORMTEXT       ___ FORMCHECKBOX _____Compensatory Leave ___ FORMCHECKBOX _____Emergency Disaster Leave ___ FORMCHECKBOX _____Family & Medical Leave spouse; ___ FORMCHECKBOX _____parent; ___ FORMCHECKBOX _____child(18 and under) ___ FORMCHECKBOX _____Family & Personal Leave (Virginia Sickness and Disability Program) ___ FORMCHECKBOX _____Family Sick Leave spouse; _ FORMCHECKBOX _ child; _ FORMCHECKBOX _ parent; _ FORMCHECKBOX _ sibling; _ FORMCHECKBOX _ other relative living in household ___ FORMCHECKBOX _____Leave without Pay Reason:  FORMTEXT       (use additional sheet if more space is needed) ___ FORMCHECKBOX _____Military Leave (attach documentation) ___ FORMCHECKBOX _____Overtime Leave ___ FORMCHECKBOX _____Personal Leave* (9 month faculty) ___ FORMCHECKBOX _____Sabbatical Leave ___ FORMCHECKBOX _____School Assistance and Volunteer Service Leave ___ FORMCHECKBOX _____Sick Leave* (traditional non VSDP) ___ FORMCHECKBOX _____Sick Leave (VSDP)) ___ FORMCHECKBOX _____Workmens Compensation Leave ___ FORMCHECKBOX _____ Other (explain)  FORMTEXT        FILLIN "You must enter your full name or your application will be rejected" \d "Must enter name here, right-click to update" \* MERGEFORMAT Enter name here, right-click to update __ FORMTEXT      ____ ________________________________________ Employees Name and Signature Date Supervisors Signature INSTRUCTIONS All salaried employees will use this form in making application for leave of absence. Application for leave of absence form should be sent immediately to the Human Resources Office by the supervisor. A Physicians certificate may be required with application for sick leave. Applications for leave without pay must be fully explained and approved by the President. (Attach Documentation) *Nine-month faculty must use personal and sick leave in half-day increments. NOTE #1 - Hour divided into tenths 0 minutes 2 mins. 59 secs Disregard 3 minutes 8 mins. 59 secs. .1 hour 9 minutes 14 mins. 59 secs .2 hour 15 minutes 20 mins. 59 secs .3 hour 21 minutes 26 mins. 59 secs .4 hour 27 minutes 32 mins. 59 secs .5 hour 33 minutes 38 mins. 59 secs .6 hour 39 minutes 44 mins. 59 secs .7 hour 45 minutes 50 mins. 59 secs .8 hour 51 minutes 56 mins. 59 secs .9 hour 57 minutes 60 mins. 1.0 hour A Annual Leave Annual leave is intended for vacation and other personal purposes. (Refer to DHRM Policy 4.10) BMOD Bone Marrow and Organ Donor Eligible Employees may use up to 30 workdays of paid leave in any calendar year, in addition to other paid leave, to donate bone marrow or other organs. (Refer to DHRM Policy 4.37) CWRL Civil and Work Related Leave Civil and Work Related leave may be used when a) serving on a jury; b) being under subpoena as a witness c) interviewing for a state job; d) to participate in resolution of work-related conflicts or of complaints of employment discrimination; or (e) to attend work-related administrative hearings as a party or witness. (Refer to DHRM Policy 4.05) EDL Emergency Disaster Leave Eligible employees may receive up to 80 hours of paid leave to give requested assistance in officially declared disaster areas, typically in cases of large scale floods, fire, ice storms, or a similarly destructive natural event. Refer to DHRM policy 4.17 for additional details. FML Family and Medical Leave Allows eligible employees who have been employed with the Commonwealth for at least 12 months and for at least 1,250 hours during the 12-month period preceding commencement of the leave, to take up to 12 weeks of paid/unpaid leave following the birth or adoption, or placement of a child with them for foster care, or for their serious personal illness, or for the illnesses of their spouse, parents, or children (18 and under). (Refer to DHRM Policy 4.20) FPL Family & Personal Leave (VA Sickness & Disability Program) This leave may be used for absences due to family and personal reasons as well as for personal illnesses or injuries. (Refer to DHRM Policy 4.57) FS Family Sick Leave (non VSDP) Family sick leave may only be used for illness, injury or death of parents, spouse, child, sibling or any relative (blood or by marriage) who resides in the employees household. ML Military Leave Military leave is granted with or without pay for active duty in the armed services of the United States or for employees who are former members of the armed services, or current members of the U.S. Reserve forces or the Commonwealth militia, or the National Defense Executive Reserve. Requests and approvals will be made in accordance with the policies and procedures of DHRM Policy 4.50 PL Personal Leave (9 month faculty) This leave may be taken at the discretion of the faculty member with supervisors approval. This leave is not intended for recreational purposes. PHEL Public Health Emergency Leave This leave provides up to 80 hours of paid leave per leave year allowing eligible employees to attend to the medical needs of self and immediate family members when communicable disease of public health threat conditions as defined by the Code of Virginia have been declared by the State Health Commissioner and Governor. Use of this leave is intended for illness directly related to the declared communicable disease threat. (Refer to DHRM Policy 4.52) SAVSL School Assistance and Volunteer Service Leave Full time employees may take up to sixteen (16) hours of leave per calendar year to perform service as a member of a service organization within their community or through organized school assistance. (Refer to DHRM policy 4.40) S Sick Leave (traditional, non-VSDP) This leave is intended for the personal use of the employee. Employees may also use sick leave to take time off from work for the illness or death of an immediate family member (bereavement/family illness). 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SL Sick Leave (VSDP) VSDP (Virginia Sickness & Disability Program) Leave may be taken for personal illnesses, injuries, preventive care and welness physician visits. 33% of an employee's sick leave can be used for qualifying FMLA absences. Sick leave cannot be carried over to the next year (January 10th January 9th) or paid out upon seperation. Accrual rates are based on years of State service. Sabbatical Leave A compensated leave of absence of one or two semesters for full-time academic faculty and up to 12 months or administrative and professional faculty and the college president. The objective of sabbatical leave is to provide activities which will improve teaching effectiveness, enhance creative and/or artistic activities, improve professional competency, and provide a renewed capacity for significant contribution of service to the college and the community at large. WC Workmens Compensation Leave A salaried employee incapacitated by injury or illness as defined by the Workmens Compensation Act is entitled to benefits provided in DHRM policy 4.60     WCC Leave Application Form (contd.) SS10132010 Use to move between fields. 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