DEC Leave of Absence

• Document No.

• Conducted on

  Date

Employee Name

• Kyle's Crew

  Ray Petrie

  Jason George

  Max Bean

  Sonny Smith

  Kyle Brelage

• Don's Crew

  Morrie Roberts

  Benny Valenzuela

  Rob Hill

  Joel Jones

  Don Utley

• Roseburg Employees

  Select Loren Waters Jim Hane Jeff Jones Jerry Alsup Wayne Higgins John Jones Dave Bly

  • Loren Waters
  • Jim Hane
  • Jeff Jones
  • Jerry Alsup
  • Wayne Higgins
  • John Jones
  • Dave Bly

• District Employees

  Phillip Larson

  Curt Woodyard

  Richard Witty

  Tyson Olds

• Yes

  No

  N/A

• Hours

• Do you have an additional type of leave to report?

  No

  Yes

• Type of Leave

  Vacation

  Sick Leave

  No Pay

  P.T.O.

• Hours

• Do you have an additional type of leave to report?

  No

  Yes

Employee Section

• Date of Absence

  Date

• Type of Leave

  Vacation

  Sick Leave

  No Pay

  P.T.O.

• Hours

• Do you have an additional type of leave to report?

  Yes

  No

• Type of Leave

  Vacation

  Sick Leave

  No Pay

  P.T.O.

• Hours

• Do you have an additional type of leave to report?

  Yes

  No

• Type of Leave

  Vacation

  Sick Leave

  No Pay

  P.T.O.

• Hours

• Do you have an additional type of leave to report?

  Yes

  No

• Type of Leave

  Vacation

  Sick Leave

  No Pay

  P.T.O.

• Hours

• Do you have an additional type of leave to report?

  Yes

  No

• Category

  Select Illness Medical Appt. Emp. Serious Health Family Serious Health Pregnancy Birth Adoption/Foster Child Non-Serious

  • Illness
  • Medical Appt.
  • Emp. Serious Health
  • Family Serious Health
  • Pregnancy
  • Birth
  • Adoption/Foster
  • Child Non-Serious

• Hours

• Do you have an additional category to report?

  Yes

  No

• Category

  Select Illness Medical Appt. Emp. Serious Health Family Serious Health Pregnancy Birth Adoption/Foster Child Non-Serious

  • Illness
  • Medical Appt.
  • Emp. Serious Health
  • Family Serious Health
  • Pregnancy
  • Birth
  • Adoption/Foster
  • Child Non-Serious

• Hours

• Do you have an additional category to report?

  Yes

  No

• Category

  Select Illness Medical Appt. Emp. Serious Health Family Serious Health Pregnancy Birth Adoption/Foster Child Non-Serious

  • Illness
  • Medical Appt.
  • Emp. Serious Health
  • Family Serious Health
  • Pregnancy
  • Birth
  • Adoption/Foster
  • Child Non-Serious

• Hours

• Do you have an additional category to report?

  Yes

  No

• Category

  Select Illness Medical Appt. Emp. Serious Health Family Serious Health Pregnancy Birth Adoption/Foster Child Non-Serious

  • Illness
  • Medical Appt.
  • Emp. Serious Health
  • Family Serious Health
  • Pregnancy
  • Birth
  • Adoption/Foster
  • Child Non-Serious

• Hours

• Do you have an additional category to report?

  Yes

  No

• Employee Signature

  Sign

Employer Section

• Recommended Action

• Department Head Signature

  Sign

• Approved

• Certification of Health Care Provider required?

  Yes

  No

• OFLA/FMLA Qualified?

  Yes

  No