DOE OTM 300-001: Hawaii Application for Leave of Absence, Certificated School-Level Employees

Under I. EMPLOYEE INFORMATION, enter the DOE Employee ID, the Name (Last, First and M.I.), the Address, City, State, Zip, Telephone, School/Office and Position.

Enter the School or Sub-Division Code, the Leave Code and the Bargaining Unit Code in the boxes.

Under II. LEAVE REQUEST, complete the appropriate subsection.

Mark Family 1, Military 4, Political 5, Other, Funeral 2, Personal, Sick 3, Health, LWOP 3, Professional Development or Vacation.

All leave requests should clearly state reasons and pertinent details.

A separate DOE OTM 300-001 form should be submitted for each type of leave requested with the applicable dates documented.

For Family leave, complete and attach Federal Form WH-380F or WH-380E(Sde). For Health leave or if Sick leave for more than five (5) consecutive days, complete Licensed Physician's Statement by completing Section IV at bottom of this form or submit a signed doctor's note verifying current health condition. Approval for sick leave is subject to the availability of accumulated sick leave.

For Funeral leave, provide relationship to deceased and address if out of state in #2.

If leave is requested because of critical illness or death in the immediate family, the name, residence, and the exact relationship must be given.

If for critical illness in the immediate family, then an accompanying statement clearly stating the imperative need of the employee's presence at the bedside is needed.

For Military leave, attach a copy of your military orders with this form (copy) to OTM Employee Records and Transactions Section, Certificated.

For Political leave, attach a separate letter justifying political appointment.

Request Leave with Pay or Leave without Pay for the calendar period.

Enter From and To as MM/DD/YYYY and the # of working days.

Is this an extended leave? Yes or No.

All extended leaves must be for the SAME REASON as the original leave.

In #2, provide any additional explanation for leave request (attach a separate sheet if necessary).

Enter the Date next to Employee Signature.

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

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

The Principal/Immediate Supervisor marks Approved or Not Approved, signs on the Principal/Immediate Supervisor Signature line and enters the Date.

The PRO/CAS marks Approved or Not Approved, signs on the PRO/CAS Signature line and enters the Date.

Complete IV. LICENSED PHYSICIAN'S STATEMENT ONLY for HEALTH LEAVE or if SICK LEAVE is for more than five (5) consecutive work days.

Write in "I certify that ____ is under my care for health reasons and is not physically able to perform his/her normal work duties from ____ to ____" with MM/DD/YYYY.

The licensed physician signs on the Licensed Physician Signature line and enters the Date, the Name of Licensed Physician (Print), the Type of Practice, the Address and the Telephone #.

When requesting leave without pay for health reasons or if sick leave is more than five (5) consecutive work days, attach a licensed physician's statement or note verifying the employee's health condition.

A separate licensed physician statement may be accepted for leave with pay for more than five (5) consecutive work days if the following statement is provided: "I certify that (Name of Employee) is under my care for health reasons and is not physically able to perform his/her normal work duties from _______ to _______."

For teachers only, the teacher calls in absence to the Teacher Substitute Employees Automated System (T-SEAS).

Teacher completes the DOE OTM 300-001 form for the principal or immediate supervisor's approval.

For absence(s) called into T-SEAS, school files and keeps the original form.

For absence(s) not called into T-SEAS, school files and keeps the original form. Also, school reports and inputs absence(s) into T-SEAS.

For school level educational officers (EOs) only, employee completes the DOE OTM 300-001 form for the principal/CAS approval.

School inputs approved leave of absences in Kronos Time & Attendance Data System and files the original form.

For all leave without pay and military leave with pay, the employee submits the DOE OTM 300-001 form and supporting attachment(s) to the principal or immediate supervisor.

Employee reports all absences in T-SEAS.

If employee is unable to report absence, SASA/timekeeper will report absence.

The principal or immediate supervisor, after recommendation for approval, submits the original DOE OTM 300-001 form and any supporting attachment(s) to the Personnel Regional Officer.

The Personnel Regional Officer, after approval action, sends the original form with any attachments to the OTM, Certificated Employee Records and Transactions Section and makes copies and distributes according to the distribution line noted in the footer of the form.

Prior to returning to work, the employee must submit a written request to the Office of Talent Management specifying Date of availability, School/office from which leave was taken, Acceptable school/office locations, Teaching specialty (e.g., elementary, secondary, English, etc.), if applicable, Present period of leave (beginning and ending dates) and Present telephone number and address.

If requesting early return from leave for health reasons, the employee also submits a medical examination clearance such as a doctor's note stating employee is physically fit to return to his/her duties.

Unless additional leave is granted, an employee who fails to return to service upon expiration of his/her leave will be terminated.

All guarantee rights are forfeited upon termination.