Form Doe Ohr 300-001 - Application For Leave Of Absence Certificated School-Level Employees - Department Of Education - State Of Hawaii

Download a blank fillable Form Doe Ohr 300-001 - Application For Leave Of Absence Certificated School-Level Employees - Department Of Education - State Of Hawaii in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Doe Ohr 300-001 - Application For Leave Of Absence Certificated School-Level Employees - Department Of Education - State Of Hawaii with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

DOE OHR 300-001

Last Revised: 01/01/2011

APPLICATION FOR LEAVE OF

Former DOE Form(s): 400, 400a, 400a.1, 400F

DEPARTMENT OF EDUCATION

ABSENCE CERTIFICATED

O fice of Human Resources

SCHOOL-LEVEL EMPLOYEES

Records and Transactions Section, Certificated

P.O. Box 2360 Honolulu, HI 96804

I. EMPLOYEE INFORMATION

Name: _____________________________________________________________

Last 4 digits of SSN: _____________________

Last

First

M.I.

Address: _________________________________________

City: _____________________ State: _______ Zip: ______________

Tel#: ________________________

School/Office: ______________________________

Position: _________________________

School or Sub-Division Code: _ _ _

Leave Code: _ _ _

Bargaining Unit Code: _ _

II. LEAVE REQUEST (Complete appropriate subsection below.)

Family

Military

Political

Other: __________________

Funeral

Sick

Personal

Health, LWOP

Personnel Development

Vacation

Provide relationship to deceased and address if out of state in

Complete and attach Federal Form

WH-380F

or WH-380E(Sde).

#2 below.

Complete Licensed Physician's Statement by completing Section IV

at bottom of this form for Health leave or if Sick leave for more

Attach a copy of your military orders with this form (copy) to

than five (5) consecutive days or submit a signed doctor's note

OHR, Records and Transactions Section, Certificated.

verifying current health condition. Approval for sick leave is

Attach a separate letter justifying political appointment.

subject to the availability of accumulated sick leave.

I hereby request the following type of leave:

Leave with Pay

Leave without Pay

for the calendar period below:

From: _______________________

To: _______________________

_________________

MM/DD/YYYY

# of working days

1 I thi

1. Is this an extended leave?

t d d l

Yes

2. Provide any additional explanation for leave request (attach a separate sheet if necessary):

________________________________________________________________________________________________________

Employee Signature: _______________________________________________________ Date: _______________________

MM/DD/YYYY

III. LEAVE APPROVAL

For sick, vacation, and personal leave, Principal/Immediate Supervisor approval required.

For family, military, personnel development, and political leave, both Principal/Immediate Supervisor and PRO/CAS approval required.

Approved

Principal/Immediate

Not Approved

Supervisor Signature:

__________________________________________

Date: _________________

MM/DD/YYYY

Approved

________________________________________

_______________

Not Approved PRO/CAS Signature:

Date:

MM/DD/YYYY

IV. LICENSED PHYSICIAN'S STATEMENT

(To be completed ONLY for HEALTH LEAVE or if SICK LEAVE is for more than five (5) consecutive work days)

I certify that _________________________________ is under my care for health reasons and is not physically able to perform

his/her normal work duties from _______________________ to ______________________.

MM/DD/YYYY

Licensed Physician Signature: ________________________________________

Date: _______________________

MM/DD/YYYY

Name of Licensed Physician (Print): __________________________________

Type of Practice: ___________________________

Address: __________________________________________________________ Tel#: ____________________________________

Distribution: Leave with Pay (Teachers): 1. Original - School; 2. Copy 1 - Employee; 3. Copy 2 - PRO (if leave exceeds one month) / Leave With Pay (EOs): 1.

Original - School; 2. Copy 1 - Employee / Leave Without Pay and Military Leave With Pay: 1. Original - OHR, Records and Transactions Section, Certificated;

2. Copy 1 - Employee; 3. Copy 2 - School; 4. Copy 3 - PRO; 5. Copy 4 - Payroll Office, Leave Accounting Section

(Page 1 of 1)