Transcription of REQUEST FOR LEAVE OF ABSENCE - gcsnc.com
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REQUEST FOR LEAVE OF ABSENCE - gcsnc.com
REQUEST FOR LEAVE OF ABSENCE Benefits Department, Guilford County Schools, 712 North Eugene Street, Greensboro, NC 27401 (medical fax) Guilford County Schools Benefits Department rev. May 2017 Section 1: Employee Information Last Name First Name Social Security Number xxx-xx-__ __ __ __ Home Address: _____ _____ Work Phone _____ Cell Phone_____ Department/School _____ Job Title_____ Date Submitted Email Second Job Title if Applicable _____ LEAVE Begin Date_____ LEAVE End Date _____ Check LEAVE Type ( REQUEST for LEAVE forms, certifications or other supporting documents should be received prior to LEAVE .) Educational LEAVE REQUEST for LEAVE Form Confirmation of Enrollment from Educational Institution Illness (Employee) REQUEST for LEAVE Form Certification of Health Care Provider for Employee s Serious Health Condition Illness (Immediate Family Member) Relationship: REQUEST for LEAVE Form Certification of Health Care Provider for Family Member s Serious Health Condition Military Caregiver REQUEST for LEAVE Form Certification f
Personal Leave (classroom teachers and media specialists only) $50/day deduction Extended Sick Leave (available to classroom teachers and media specialists only) $50/day deduction Voluntary Shared Leave is for a serious medical condition for yourself or immediate family.
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