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Download Leave of Absence Request Form -  ??Web view2017-05-17LEAVE REQUEST: Email a scanned copy ... Leave of Absence Request Form Page 1 of 2. 29-Jun-2016. Leave of Absence Request Form. Title: Leave of Absence Request Form Author: rmackie Last modified by: Government of

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Leave of Absence Request Form

Employee Name:

Employee #:Ministry:

Assignment #:

LEAVE REQUEST:

Email a scanned copy of the approved Leave of Absence Request Form to the Benefit Services Team at the Employee Service Centre at HRSC HRSC@gov.sk.ca. Please be sure to indicate MIN(LOA) at the beginning of the Subject Line of your email.

To ensure timely processing, please submit the approved Leave of Absence Request Form to the Employee Service Centre a minimum of 2 weeks PRIOR to the commencement or extension of leave.

Questions concerning leaves of absence policy should be directed to your Human Resources Services Team.

Questions regarding benefits while on leave should be directed to the Benefit Services Team at the Employee Service Centre.

Section A:Commencing a Leave of Absence

Leave Start Date:

Leave End Date:

Please indicate one:

FORMCHECKBOX Definite Leave Without Pay: Human Resource Manual Section: PS 702

FORMCHECKBOX Adoption (Mandatory)

FORMCHECKBOX Medical (Mandatory)

FORMCHECKBOX Apprenticeship Training

FORMCHECKBOX Moving to Term/Non Perm Position Within GoS (Discretionary)

FORMCHECKBOX Compassionate Care (Mandatory)

FORMCHECKBOX Moving to Term/Non Perm Position Outside GoS (Discretionary)

FORMCHECKBOX Crime-Related Child Death or Disappearance (Mandatory) FORMCHECKBOX Parental (Mandatory)

FORMCHECKBOX Critically Ill Child Care (Mandatory)

FORMCHECKBOX Personal (Discretionary)

FORMCHECKBOX Learning and Development / Education (Discretionary) FORMCHECKBOX Spousal Relocation (Discretionary)

FORMCHECKBOX Maternity (Mandatory)

FORMCHECKBOX Other (please indicate reason):

OR

FORMCHECKBOX Definite Leave With Pay: Human Resource Manual Section: PS 701-A

FORMCHECKBOX Deferred Salary (PS 713)

FORMCHECKBOX Education (Discretionary)

FORMCHECKBOX Other (please indicate reason):

OR

FORMCHECKBOX Indefinite Leave Without Pay: Human Resource Manual Section: PS 703

FORMCHECKBOX Adjudicated Prolonged Illness (Mandatory)

FORMCHECKBOX Crown Employment (Mandatory)

FORMCHECKBOX Job Abolishment (Mandatory)

FORMCHECKBOX Workers Compensation (Mandatory)

FORMCHECKBOX Other (please indicate reason):

Section B:ExtenDING a Leave of Absence

New Expiry Date:

FORMCHECKBOX Definite Leave of Absence (indicate leave reason, ie. maternity):

OR

FORMCHECKBOX Indefinite Leave of Absence (indicate leave reason, ie. disability):

Employee Signature: _____________________________

Date:

Supervisor / Manager Signature: _____________________________

Date:

Phone #:

FORMCHECKBOX Recommend FORMCHECKBOX Not Recommended Reason:

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Permanent Head / Delegate Signature: _____________________________Date:

Phone #:

FORMCHECKBOX Approved FORMCHECKBOX Denied Reason:

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The following approval is required for all Discretionary Indefinite Leave of Absence requests, CUPE Definite Leave of Absence requests greater than 3 months and all CUPE Indefinite Leave of Absence requests. Please contact your HR Service Team should you have any questions.PSC HR Service Team Signature: _____________________________

Date:

Phone #:

FORMCHECKBOX Approved FORMCHECKBOX Denied Reason:

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PLEASE SEE REVERSE FOR IMPORTANT INFORMATION

IMPORTANT NOTE: While on Definite or Indefinite Leave of Absence Without Pay, you may continue in the Government of Saskatchewan Group Life Insurance Plan and Disability Income Plan (DIP) for OutofScope and CUPE employees, up to a maximum of three (3) years. Participation in the SGEU LTD plan is mandatory for the first year while on leave of absence. To continue coverage in the Government of Saskatchewan Group Life Insurance Plan and DIP, you must pay the employee share of the premiums. Premiums must be received by the Employee Service Centre, within two (2) weeks of your leave commencing.

Failure to elect to continue coverage in the Group Life Insurance Plan and Disability Income Plan (DIP) for OutofScope and CUPE employees, and/or failure to submit your premiums to the Employee Service Centre will result in termination of coverage for the duration of your leave, including any extensions, as well as on termination or retirement immediately following a leave of absence. Coverage under these plans cannot be obtained retroactively.

Upon receipt of the approved Leave of Absence Request and Notification Form, the Employee Service Centre will contact you by letter and outline your options to elect continued coverage under the plan(s), provide premium information, as well as other important employment and benefit information while on leave.

If you have any questions, please contact the Employee Service Centre at HRSC@gov.sk.ca by telephone at 306-798-0000 or toll free at 18778525808.

Leave of Absence Request Form

Leave of Absence Request Form Page 1 of 229-Jun-2016

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