<p> CHARLES COUNTY PUBLIC SCHOOLS EMPLOYEE LEAVE STATEMENT CERTIFIED</p><p>EMPLOYEE NAME EMPLOYEE ID # SCHOOL</p><p>DATES # HOURS LEAVE DESCRIPTION ANNUAL LEAVE Twelve-month Employees only.</p><p>PERSONAL LEAVE 10-Month, 10.5-Month, and 11-Month Employees only. PLEASE NOTE: ALL INFORMATION AND/OR ATTACHMENTS ARE NECESSARY IN ORDER TO BE GRANTED ADMINISTRATIVE LEAVE.</p><p>FUNERAL - IMMEDIATE FAMILY or anyone who has lived regularly in the household. ** MAXIMUM: THE EQUIVALENT OF FIVE (5) WORK DAYS. RELATIONSHIP DATE OF DEATH </p><p>FUNERAL - OTHER limited to two (2) instances, up to two (2) days each per fiscal year RELATIONSHIP DATE OF DEATH </p><p>COURT/LEGAL SUMMONS Employee’s summons to appear as witness or verdict of not guilty MUST be attached to avoid loss of leave and/or pay.</p><p>JURY DUTY SUMMONS Daily attendance papers MUST be attached to avoid loss of leave and/or pay.</p><p>CONFERENCES, ON OR OFF-SITE MEETINGS, WORKSHOPS, IN-SERVICES, etc. EVENT LOCATION</p><p>WORKER’S COMPENSATION Sick leave charged until approved by Risk Manager.</p><p>SICK LEAVE - EMPLOYEE and/or FAMILY ILLNESS A doctor’s statement may be required after the equivalent of three (3) consecutive workdays.</p><p>RELIGIOUS and/or IDEOLOGICAL OBSERVANCE Two (2) days per fiscal year permitted (deducted fom sick leave) EACC employees only. </p><p>OTHER Specify LWOP (Leave Without Pay), etc. ______</p><p>______Total Hours Leave Requested by Employee </p><p>______Employee Signature Date</p><p>______Supervisor Signature Date</p><p>*FOR CLARIFICATION, PLEASE REFER TO THE EACC NEGOTIATED AGREEMENT.</p><p>Revised: August 2014</p>