Employee Leave Request
Please correct the following errors.
Email :
Name :
Address:
Street 1
Street 2
City, State, Zip:
City
State
Alabama
Alaska
Arizona
Arkansas
Armed Forces Asia
Armed Forces Europe
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
Hampshire
Jersey
Mexico
York
Carolina
Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Island
Carolina
Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Virginia
Wisconsin
Wyoming
ZIP
Contact Phone:
Telephone
Department:
OFA
OAMS
OES
AES
Transportation
Building and Grounds
Central Office/ Administration
Please choose only the option that applies to your leave and answers required information accordingly:
Parental Leave Request
Medical Leave Request
Discretionary Leave Request
Parental Leave Request
Parental Leave Type
Birth Mother
Non-Birth Parent
Please upload a doctor's note if you currently have one. If you do not, please submit to the District Office as soon as you have received one.
Attach
Attach
Child Expected Birthdate:
(MM/DD/YYYY)
Leave Start Date
(MM/DD/YYYY)
Leave End Date
(MM/DD/YYYY)
Medical Leave Request
Reason for Medical Leave
Please upload a doctor's note if you currently have one. If you do not, please submit to the District Office as soon as you have received one.
Attach
Attach
Leave Start Date
(MM/DD/YYYY)
Leave End Date
(MM/DD/YYYY)
Number of Sick Days to be used:
If sick days are exhausted are you requesting days from sick bank?
Yes
No
Sick Bank Days Requested (enter N/A if you do not intend to use sick bank)
Discretionary Leave Request
Reason for Request:
Leave Start Date:
(MM/DD/YYYY)
Leave End Date:
(MM/DD/YYYY)
Number of Days Requested:
Electronic Signature, Certification, and Acknowledgement.
You must check both boxes in order to submit. Check all that apply.
The information provided on this form is accurate and complete.
I understand that providing false or misleading information may result in disciplinary action, up to and including termination.
What would you like to submit?
Question
Comment
Suggestion
Concern
Compliment
Tell us who you are
(Select one or more)
Owego-Apalachin CSD Student
Owego-Apalachin CSD Parent/Guardian
Owego-Apalachin CSD Employee
Community Member
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