ࡱ> uwt @ N;bjbjqq "J*|||||||$"(^^^^9 ET!!!!!!!$#R/&@"]|99"||^^o"HHHL|^|^!H!HH||H^ k@ HH"0"Ho&Jo&H||||o&|H=QH_ k==="" T > T Human Resource ServicesRequest for Disability Leave of AbsenceCertificated Employees Name:  FORMTEXT      Social Security Number:  FORMTEXT     FORMTEXT    FORMTEXT     Street Address:  FORMTEXT      City/State/Zip:  FORMTEXT      Home Phone: FORMTEXT     FORMTEXT     FORMTEXT     Work Phone: FORMTEXT     FORMTEXT     FORMTEXT     Position Title:  FORMTEXT      Hire Date in District (mm/dd/yy): Date Leave Begins (mm/dd/yy):  FORMTEXT    FORMTEXT    FORMTEXT   Date Leave Ends (mm/dd/yy): FORMTEXT    FORMTEXT    FORMTEXT   School/Department:  FORMTEXT      Subject/Grade Level (if applicable):  FORMTEXT      Reason for Leave: (Please refer to your union contract.)  FORMTEXT      The request for this leave of absence is made in accordance with the provisions of the California State Education Code (Section44986), which provide that any regular employee of the District may, at the discretion of the Board, be granted leave of absence for reasons of disability without pay. I understand that a disability leave of absence shall continue only for the term of the eligible disability, and in no case shall it exceed thirty-nine (39) months (Education Code 44986). I further understand that the leave will be granted only upon notification from the State Teachers Retirement System to the District that the employee has been accepted for a disability allowance by the State Teachers Retirement System and with the approval of the Superintendent. I also understand that the district agrees to pay the medical insurance premiums for employees who have served ten consecutive years of service in the District immediately prior to the beginning of the disability leave of absence. A Board-approved leave of absence shall not constitute a break in service for the purpose of determining eligibility for this benefit. I further understand that upon reaching age sixty (60), the disability leave of absence will be converted to service retirement unless otherwise notified by the State Teachers Retirement System. I further understand that I am to give written notice of my intention to return from this leave not less than thirty (30) days before the expiration date of the leave, and that I am to furnish with this notice a written statement from a physician to the effect that I am physically able to resume my duties on a full-time basis.( My address while on leave will be: FORMTEXT      If the above request is granted, I understand that I will: 1. Contact the Benefits Office regarding benefits and insurance coverage (if any) during my leave of absence. 2. Comply with the requirements and conditions set forth in the union contract48$ & : < > D F H J ^ ` b f h j l     < > R T V \ ^ ` b v j>Uj=Uj-=Uj;Uj';Uj:UjUmHnHujI:U 5CJ$aJ$5B*CJ$aJ$ph59B*CJ$aJ$ph jU;468$IfNkdm8$$Ifl40T*`H$4 la $$Ifa$ $IfN;95PNkd9$$Ifl40T* H$4 la $$Ifa$$Ifhkd8$$Ifl40T* H$  4 lap$ H j Akd<$$Iflr-o#'* 0 +4 la $($Ifa$($If " $ < ` 0 zzzzzz $($Ifa$qkd>$$Ifl0-*s0 +4 la($If v x z   " $ , . R T h j l v x      " $ 8 : < @ B D F Z \ ^ b jEUjDUj-DU h.CJj'CUj@Uj}@Uj@Uj?UjUmHnHu jUj?U?0 2 z ($IfkdiA$$Iflִr -o#'*  0 +    4 laz " D f  zzzzzz $($Ifa$qkdC$$Ifl0-*s0 +4 la($If b d  , . B D F P R | 4:<PRT^`d.ưƪ jCJhCJaJ hi/CJ>*CJjJU>*j IUCJjHUjoFUjFUjUmHnHujEU h.CJ jU;  T ($IfkdF$$Iflִ -!8$l'*r   3440 +    4 laT :b| $$Ifa$qkd}I$$Ifl0-*s0 +4 la($IfbdZ/`$d$<$Ifa$^kdJ$$Ifl* +0 +4 la $<$Ifa$ $<$Ifa$^kd K$$Ifl* +0 +4 la  rjl8/808`8a88889,9999999e:f::(;N;6CJ j5 hdaJ hi/CJU hdCJhCJaJCJaJjUmHnHu jUjKU#d,8a8znVVA h@hd$$If^h`$ h@0d$$If^`0a$ h@<$IfkdL$$IflF (*  0 +    4 la for the bargaining unit to which I belong. 3. Request any needed extension of leave in writing. 4. Give written notice no less than thirty (30) days before the expiration date of my leave regarding whether or not I intend to return.Employee Signature: Date: For Human Resource Services Use OnlyDisability allowance verified with STRS by:Date: Ten consecutive years of service in district immediately prior to leave date: ( Yes ( NoHold Position: Transfer to Unassigned: Recommendation for leave approved by:Date: Leave of absence granted in accordance with the above agreement:Signature: Director, Human Resource ServicesDateAgenda Date: T.A.P. No. cc:Principal or Supervisor, Employee, Personnel File Reference: Education Codes 22126 and 44986 05/13/08, Rev. 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