**GCCCB-E - REQUEST FOR TIME UNDER THE SMALL NECESSITIES LEAVE ACT**
**Adoption Date:** 01/06/2015
(To be completed and submitted to your principal with a copy to the superintendent of schools.)
I am requesting the following time off for reasons covered under the Small Necessities Leave Act. If this need was foreseeable, I have provided at least seven (7) days notice, if it was not foreseeable, I have provided as much notice as possible. I understand that if eligible, this time will be counted towards the twenty-four (24) hour time bank allowed per calendar year under the Small Necessities Leave Act and the following South Hadley Public Schools’ Policy.
Requested time off: (date and time)
This time is for one of the reasons specified below:
- To participate in school activities directly related to educational advancement of a son or daughter of the employee, such as parent-teacher conferences or interviewing for a new school (school is a public or private elementary or secondary school, a Head Start program and/or a children’s day care facility);
- To accompany the son or daughter of the employee to routine medical or dental appointments, such as check-ups or vaccinations; or
- To accompany an elderly relative of the employee to routine medical or dental appointments and for “other professional services related to the elder’s care”, such as interviewing at nursing or group homes. (An elderly relative is defined as one who is sixty (60) years of age or older and related by blood or marriage.)
I understand that if eligible, I will be using any paid time which I have available to cover this Small Necessities Leave Act time. If I do not have any paid time left, I understand that the time taken will be unpaid.
Employee Signature:
Date:
Approval and Designation of SNLA Time
Date:
Request received from:
Department: Date of hire:
No. of hours worked in previous twelve (12) months:
Time requested: (date and time):
SNLA time taken this calendar year:
As of this date: SNLA time remaining:
Paid time remaining:
Approved:
As requested
With the following modifications:
Not Approved:
Employee is ineligible due to length of employment, i.e. less than one year.
Employee has worked less than 1250 hours in the previous 12 months.
The reason for the requested time off does not fall under the guidelines of the
Act.
SNLA entitlement has been exhausted for the current period.
Other:
Principal: Date:
Copies distributed: Employee __________ Principal: _________________
Superintendent: Payroll:
Name:
Anticipated dates of leave of absence:
Types of leave:
Date of hire:
Benefit time as of:
Personal time
Vacation time
Total
As of worked hours in the previous fifty-two (52) weeks.
Eligible for SNLA? Yes No
Previous SNLA and dates:
Comments:
Approved by: Date: