Std 634 Form – Fill Out and Use This PDF

STATE OF CALIFORNIA

ABSENCE AND ADDITIONAL TIME WORKED REPORT

STD. 634 (REV.5-98)

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6. ABSENCE WITHOUT PAY

ABSENCE WITHOUT LEAVE (AWOL) (19996.2 OR 19572)

TEMPORARY LEAVE

(30 Calendar days or less)

ABSENCEWHILE

ON PROBATION(ML)

(FM)

(FMLA)

8. REASON FOR ABSENCE OR EXTRA HOURS WORKED

MEDICAL APPOINTMENT

DENTAL APPOINTMENT

10. RECOMMENDATION AND SUBSTANTIATION OF SUPERVISOR

SUBSTANTIATION SHALL BE REQUIRED FOR SICK LEAVE OF MORE THAN TWO CONSECUTIVE WORK DAYS. SHOW METHOD OF VERIFICATION BELOW.

11.STATEMENT BY PHYSICIAN (Not to be completed by attending physician for industrial illness or injury.)

DOCTOR STATEMENT ATTACHED

AS PHYSICIAN, I EXAMINED AND TREATED OR PRESCRIBED FOR

THIS PATIENT ON THESE DATES

THE ILLNESS OR INJURY CAUSING THE DISABILITY WAS

12. PERIOD ON DISABILITY COMPENSATION

13. DISABILITY COMPENSATION SUPPLEMENT

14.OFFICIAL DEPARTMENTAL ACTION

APPROVED

DISAPPROVED

REVIEWED BY

GENERAL INFORMATION

1.All absences or additional hours worked by full-time or part-time employees should be reported on one form STD. 634 for each pay period. Report all time worked for permanent intermittent and part-time employees.

2.Prepare the number of copies required by our department. Employees who want a copy for their own records, indicating supervisor's signature, may prepare an extra copy.

1.Enter pay period, month, and year, and complete other boxes as required by your department.

2-4. Complete name, social security number, and position number.

5.Absences with Pay--Check appropriate box, indicating type(s) of absence(s).

6.Absences Without Pay (Dock)--Complete all boxes, indicating type of unpaid absence and if the current pay period is qualified or nonqualified. Last box can be checked if employee is serving a probationary period to determine if employee will complete required number of working days.

Qualifying Pay Period--Eleven (11) or more paid days in a monthly pay period.

Nonqualifying Pay Period--Less than eleven (11) paid days in a monthly pay period.

Note: If the employee is absent without pay for more than eleven (11) consecutive working days, which falls between two (2) consecutive otherwise qualifying pay period, one (1) pay period shall be disqualifying.

7.Dates of Absences and Extra Hours Worked

7a. Enter time to be paid for each day, including paid absence hours for intermittent or part-time employees.

Note: Enter all hours to be paid in the total column.

7b. Sick and Sick Family--Provisions on the usage of sick and family sick leave are outlined by the memorandum of understanding between your exclusive representatives and the State of California.

Indicate sick leave hours with a symbol "S" or "SF" on date of absence. If more than two (2) hours are needed for a doctor's appointment, the reason should be stated in Item 8. Enter the symbol and the number of hours under the number(s) corresponding to the duties being reported.

7c. Bereavement Leave--Provisions for bereavement leave are outlined by the memorandum of understanding between your exclusive representative and the State of California.

Jury Duty or Subpoenaed Witness--An employee may be absent with pay for time actually served to perform jury duty or for time subpoenaed as a witness in a court case when the employee is neither a party nor an expert witness, providing the employee remits the fee to the State. If the fee is retained, either a charge is made against the employee's accumulated leave balance or absence is without pay. It is up to the employee to demand of the party requesting their appearance a subpoena and whatever fees and travel allowance that may be allowed by law. Witness fees for a civil trial are governed by Government Code Sections 68093-68096 and the fee for a criminal trial is governed by Penal Code Section 1329. The employee may keep travel allowance.

7g. Post proper symbol and number of hours for type of absence reporting.

Approved absence without pay--Approved dock

Absence without pay--AWOL

7h. Enter symbols and hours to be compensated at straight time as indicated

7i. Enter symbols and hours to be compensated at premium time as indicated below (Personnel Office will convert to time and one-half (1-1/2):

Note: Total column may be used for Items 7b through 7i.

8.Reason for Absence or Extra Hours Worked--Employee must indicate reason for sick leave absences, including relationship of family member when reporting family sick leave.

7d. Vacation may be used in 30 minute or one (1) hour increments as outlined by the memorandum of understanding between your exclusive representative and the State of California and is shown on the appropriate date with the symbol "V"..

An absence can be charged against vacation credits only when approved by the appointing power. The time at which vacation shall be taken may be specified to suit the convenience of the department. Vacation cannot be taken as an absolute right unless the appointing power does not provide a vacation for the employee for two successive years.

7e. Annual Leave--The "A/L" symbol shall be used to indicate when annual leave credits have been used.

7f. Post proper symbol and number of hours for type of absence being reported.

ML—Monitoring Leave—eligible employees may recieve up to 40 hours mentoring leave per claendar year once they have used an equal amount of their leave or personal time for this activity.

FM—Family and Medical Leave Act—under certain conditions, entitles employees up to 12 weeks of unpaid leave per year.

Paid Educational Leave--Following completion of twelve (12) qualifying pay periods of continuous service, a full-time employee in State civil service employed in a position requiring teaching certification qualification shall be allowed fifteen (15) days credit or educational leave with pay. Thereafter, on the first (1st) of the pay period following each additional qualifying pay period of service, he/she shall be allowed one and one-fourth (1-1/4) days credit for educational leave with pay. The employee may earn or use educational leave credit only while in a position requiring teacher certifica- tion qualifications. The granting of paid educational leave is at the discretion of the appointing power.

Military Leave--Attach a copy of any applicable military order. Every calendar day must be recorded, including any Saturday, Sunday, or holiday.

Note: This item also can be used for reporting reasons for overtime hours worked or for unpaid absences.

9.Employee's Responsibility and Signature--Employees have the responsibility to give their supervisor advance notification when they anticipate a future absence. When unanticipated emergency causes the absence, the employees are responsible for notifying supervisor as soon as possible and keeping their supervisor informed as to the possible date of return. Employees are also responsible for promptly reviewing and signing their absence report at the end of the pay period and submitting to supervisor.

10.Recommendation of Supervisor's Responsibility--Each supervisor is responsible for seeing that employees comply with the regulations governing absence from work. The supervisor is expected to recommend against approval of sick leave absences when satisfactory evidence as to need is not presented. Supervisor is then responsible for promptly reviewing and signing the employee's absence report and forwarding it to the Personnel Office.

Before recommending approval for sick leave by an INTERMITTENT EM- PLOYEE, supervisor shall certify that the employee was scheduled to work during the hours reported for sick leave.

Note: Methods of verification can include telephone, physician statement, home or hospital visit.

11.Statements by Physicians--If physician statement is attached, check first box and do not complete other information in this item.

If supervisor has requested the physician's verrification on this form, second box is checked and the doctor completes each item and signs the form.

12.Applicable information regarding absences due to industrial injury or

13.Illness should be recorded in this area.

14.Completed by Personnel Office only.