Hawaii Doe Leave Codes Details

The Ohr Form 400A is a document used to report an organization’s exempt status to the IRS. This form must be filed annually, and it provides the IRS with information about the organization’s exempt status, including its tax filing history and contact information. Though the form may seem daunting at first glance, it’s important for organizations with exempt status to file it every year. Failing to do so can result in penalties from the IRS. Luckily, there are plenty of resources available to help you complete the form accurately and on time.

You will discover information regarding the type of form you want to submit in the table. It will show you the time it will take to complete ohr form 400a, exactly what parts you will need to fill in and several further specific details.

QuestionAnswer
Form NameOhr Form 400A
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshawaii doe school use fillable form, maritime leave request form, hawaii doe leave of absence codes, tseas hawaii

Form Preview Example

OHR Form 400a (Revised 10/2006)

 

APPLICATION FOR LEAVE OF ABSENCE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SCHOOL-LEVEL CERTIFICATED EMPLOYEES

 

 

 

 

Soc. Sec. No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATE OF HAWAII

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEPARTMENT OF EDUCATION

 

 

 

 

Sch. or Sub-Div. Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OFFICE OF HUMAN RESOURCES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CERTIFICATED RECORDS AND TRANSACTIONS

 

 

 

 

Type of Leave Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P. O. BOX 2360

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HONOLULU, HAWAII

96804

 

 

 

 

 

 

 

Bargaining Unit Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION I. EMPLOYEE INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Mailing Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last

 

First

 

 

 

 

M.I.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number

 

Street

 

3.

 

Home Telephone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

 

Zip

 

 

SECTION II. LEAVE REQUEST (complete appropriate subsection below)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sick Leave

 

 

 

 

 

 

 

 

 

 

 

 

 

Vacation

 

 

 

 

 

 

 

 

Family Leave

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Personal Leave

 

 

 

 

 

 

 

 

Funeral

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Personnel Development Leave

 

 

 

 

 

 

 

 

Health

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Leave

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FILL IN #1 OR #2 BELOW:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

I hereby request LEAVE WITH PAY for the calendar period as follows:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From

 

 

 

 

 

 

 

 

 

 

 

 

 

to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

 

Day

 

Year

 

 

 

 

Month

 

 

Day

 

 

 

 

Year

# of Working Days

 

2.

 

I hereby request LEAVE WITHOUT PAY for the calendar period as follows:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From

 

 

 

 

 

 

 

 

 

 

 

 

 

to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

 

Day

 

Year

 

 

 

 

Month

 

 

Day

 

 

 

 

Year

# of Working Days

 

 

 

 

 

 

 

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Is this an extended leave?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State reason(s) for leave (append if necessary)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signed:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

School or Office

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION III. LEAVE APPROVAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Recommend:

 

Approval

 

 

 

Disapproval

 

 

 

 

 

 

 

 

 

 

 

Approval

 

 

 

 

 

 

 

 

 

 

 

 

Disapproval

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signed:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signed:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Principal/Immediate Supervisor

 

 

 

 

 

 

 

 

 

Personnel Regional Officer or Complex Area Superintendent

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION IV. DOCTOR’S STATEMENT (to be completed ONLY for HEALTH LEAVE or if SICK LEAVE is for more than five 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

 

 

Month/Day/Year

 

Month/Day/Year

 

 

 

 

 

 

 

 

Signature of Licensed Physician

 

 

 

 

Date

See Page 2 for Instructions, General Information and Distribution

INSTRUCTIONS:

1.All leave requests should clearly state reasons and pertinent details must be clearly stated.

2.All extended leaves without pay must be for the SAME REASON as the original leave.

3.The Doctor’s Statement (page 1) MUST BE COMPLETED when requesting leave without pay for health reasons and if sick leave is for more than five consecutive work days.

4.If leave is requested because of critical illness or death in the immediate family, the name, residence, and the exact relationship must be given. In addition, if for critical illness in the immediate family, then an accompanying statement clearly stating the imperative need of the teacher’s presence at the bedside is needed.

ROUTING FOR ALL LEAVE WITHOUT PAY AND MILITARY LEAVE WITH PAY:

1.The employee submits application and verifying attachment(s) to the principal or immediate supervisor.

2.The principal or immediate supervisor, after approval recommendation, submits the application and any verifying attachment to the Personnel Regional Officer.

3.The Personnel Regional Officer, after approval action, makes copies and distributes as follows: * OHR, Certificated Records and Transactions

*Employee

*School for submittal to the Payroll Office

*Personnel Regional Office

*School

ROUTING FOR ALL LEAVE WITH PAY:

1.The teacher calls in absence to the Teachers Substitute Employees Automated System (TSEAS).

2.The employee completes the request for leave of absence for the principal or immediate supervisor’s approval.

3.Except for teachers, the school makes copies and distributes (as stated above).

4.For teachers only—the school makes the copies and distributes (as stated above) only if the absence is NOT called in to TSEAS.

GENERAL INFORMATION

The following are provided as general information. Employees are advised to review the specific regulations and procedures in the School Code to understand the terms, conditions, and employee responsibilities that apply to their leave situations.

A.Employee Responsibility While on Leave

1.Keeps the Department informed of intent to return by submitting a Form 101 when requested or by writing directly to the Department (school principal or district personnel officer) at least 90 days prior to the expiration date of his/her leave.

2.Keeps the Department informed of current leave address to insure that he/she receives all correspondence sent to him/her by the Department.

3.Initiates direct monthly payment(s) to maintain Health Fund Benefits as required during leaves of absence without pay.

B.Requesting Early Return From Leave (Reference: Regulation #5400)

Prior to returning to work, the employee must submit a written request to the Office of Human Resources specifying the following information:

1.Date of availability,

2.Acceptable locations,

3.Present period of leave (beginning and ending dates),

4.School from which leave was taken,

5.Teaching specialty (elementary, secondary, English, etc.),

6.Present telephone number and address.

Additionally, if requesting early return from leave without pay for health reasons, the employee also submits a medical examination clearance (Form 132, Physical Examination of Employee).

C.Failure to Return to Duty

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.

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