APPENDIX D

2014 SUMMER

SERVICES FORMS

ADVANCED ACADEMIC PROGRAMS - DUAL ENROLLMENT Dual Enrollment Authorization Request Form (FM-6477) DIVISION OF SPECIAL EDUCATION - EXTENDED SCHOOL YEAR 2014 Extended School Year (ESY) and Summer Services Information Worksheet 2014 Extended School Year (ESY) Transportation List (FM-7042)

School-Based Extended School Year (ESY) Services Log: 2014 (FM-6574) HUMAN RESOURCES Probationary/Annual Contract Waiver Request for Summer 2014 PAYROLL Application for Short Term Leave Form (FM-5949)

DUAL ENROLLMENTAUTHORIZATION REQUEST FORM

Student Signature Date P arent/Guardian's Signature Date

Counselor's Signature Principal's Signature

Any questions, please call Advanced Academic Programs at (305) 995-1934.

DUAL ENROLLMENT BOOK VOUCHER

To the student: When available. students will be siven a used book. Students are responsible for returning all textbooksissued during each semester of study. Students will be held financially responsible for any textbook(s) not returned to theirhigh school. Textbook alfiliated costs for licensing fees or electronic media access which are password protected and cannot be

returned to the District as its ofthe student.

Representative's Tille DATE

Gold Copy - School

FM-6477 Rev. (08-13)

PLEASE PRINT CLEARLY

Student Name Date of Birth Student ID# Post-Secondarv Institution

M-DCPS #

MDC/FIU #

! FIU

! MDC

TO BE COMPLETED BY STUDENT'S COLTNSELOR

BOOK TITLBCOURSE NAME

TOTAL: $

White Coy - District Ofice; Yellow Copy - Student; Pink Copy College/University;

Pag

e 1 o

f 5

2014 E

XT

EN

DE

D S

CH

OO

L Y

EA

R (

ES

Y)

AN

D S

UM

ME

R S

ER

VIC

ES

IN

FO

RM

AT

ION

WO

RK

SH

EE

T

TO

BE

CO

MP

LE

TE

D O

NL

Y F

OR

ST

UD

EN

TS

RE

QU

IRIN

G S

ER

VIC

ES

LIS

TE

D O

N P

AG

E 1

(DU

E D

AT

E –

MA

Y 1

6,

201

4)

ES

Y /

Su

mm

er S

chool

Sit

e: _

_______________________________ W

L#_______

_ D

ate

Su

bm

itte

d _

_________

_________

Cu

rren

t S

chool:

_____________________ W

L#________ C

on

tact

: ________________

_________ P

hon

e: _

___

__________

C

om

ple

te p

ages

1-5

for

studen

ts w

ith d

isab

ilit

ies

atte

ndin

g E

SY

or

Sum

mer

Ser

vic

es t

hat

nee

d s

upple

men

tary

or

rela

ted s

ervic

es w

hic

h

req

uir

es s

pec

ial

pla

nnin

g a

nd p

repar

atio

n.

Com

ple

te a

sep

arat

e fo

rm f

or

each

sch

ool

site

. E

SY

/Sum

mer

Sch

ool

site

s pro

vid

ing s

ervic

es t

o

thei

r cu

rren

t st

uden

ts m

ust

als

o c

om

ple

te t

his

char

t. P

leas

e em

ail

or

fax

com

ple

ted p

ages

to t

he

SP

ED

Ser

vic

e C

ente

r and t

he

Dis

tric

t

Off

ice

by M

ay 1

6,

201

4 s

o t

hat

nec

essa

ry p

repar

atio

ns

can b

e m

ade.

U

se t

he

codes

lis

ted o

n p

age

2 t

o c

om

ple

te t

he

equip

men

t an

d

assi

stiv

e te

chnolo

gy c

olu

mns,

as

nee

ded

.

Stu

den

t N

am

e

ID #

G

rad

e L

evel

(201

4-2

015

)

Prim

ary

Excep

t.

NU

RS

S

pecia

lize

d

Foo

d P

rep

.

ITN

VI

ITN

DH

OH

Ori

en

t. &

Mo

bil

ity

Ad

ap

tive

Eq

uip

men

t

Ass

isti

ve

Tech

.

1

2

3

4

5

6

7

8

9

1

0

1

1

1

2

AD

AP

TIV

E E

QU

IPM

EN

T A

ND

AS

SIS

TIV

E T

EC

HN

OL

OG

Y C

OD

ES

R

EF

ER

EN

CE

PA

GE

2

SP

EC

IAL

FO

OD

PR

EP

AR

AT

ION

RE

QU

ES

T

CO

MP

LE

TE

PA

GE

3

AS

SIS

TIV

E T

EC

HN

OL

OG

Y T

RA

NS

FE

R R

EQ

UE

ST

C

OM

PL

ET

E P

AG

E 4

EQ

UIP

ME

NT

TR

AN

SF

ER

RE

QU

ES

T

CO

MP

LE

TE

PA

GE

5

Pag

e 2 o

f 5

2014 E

XT

EN

DE

D S

CH

OO

L Y

EA

R A

ND

SU

MM

ER

SE

RV

ICE

S I

NF

OR

MA

TIO

N W

OR

KS

HE

ET

AD

AP

TIV

E E

QU

IPM

EN

T A

ND

AS

SIS

TIV

E T

EC

HN

OL

OG

Y C

OD

ES

AD

AP

TIV

E E

QU

IPM

EN

T

CO

DE

S

SP

EC

IFY

*

AS

SIS

TIV

E T

EC

HN

OL

OG

Y

CO

DE

S

SP

EC

IFY

*

Chan

gin

g T

able

C

T

A

mpli

fica

tion S

yst

em

AS

Lif

t*

LIF

T

B

atte

ry/E

lect

rica

l A

cces

s D

evic

e B

EA

D

P

rivac

y S

cree

n

PS

Com

pute

r A

cces

s D

evic

e C

AD

Adap

tive

Chai

r A

C

V

isio

n E

nhan

ce E

quip

men

t V

EE

Adap

tive

Toil

et

AT

Voic

e O

utp

ut

Dev

ice

VO

CD

Adap

tive

Toil

et S

eat

AT

S

W

riti

ng A

cces

s D

evic

e W

AD

Adap

tive

Fee

din

g E

qu

ipm

ent*

A

FE

Oth

er*

O

TH

Pro

ne

Sta

tionar

y S

tand

er

PS

S

Supin

e S

tati

on

ary S

tan

der

S

SS

P

osi

tionin

g M

at

PO

S

Oth

er*

OT

H

EM

AIL

OR

FA

X A

LL

CO

MP

LE

TE

D P

AG

ES

TO

TH

E E

SE

SE

RV

ICE

CE

NT

ER

AN

D D

IST

RIC

T O

FF

ICE

ON

OR

BE

FO

RE

MA

Y 1

6, 2014

ES

E S

ER

VIC

E C

EN

TE

R

NA

ME

T

ITL

E

EM

AIL

F

AX

Nort

h C

entr

al

Alf

redia

Robin

son

E

SE

Inst

ruct

ional

Super

vis

or

alfr

edia

Rob@

dad

esch

ools

.net

3

05-8

27

-30

26

Nort

h

Kat

e C

adie

ux

E

SE

Inst

ruct

ional

Super

vis

or

kca

die

ux

@dad

esch

ools

.net

3

05-8

27

-30

26

South

Cen

tral

K

ath

y M

aguir

e E

SE

Inst

ruct

ional

Super

vis

or

km

aguir

e@dad

esch

ools

.net

7

86-2

68

-47

58

South

H

elen

e C

hai

t E

SE

Inst

ruct

ional

Super

vis

or

chai

th@

dad

esch

ools

.net

3

05-2

42

-84

33

Char

ter

Sch

ool

Kar

en B

oyce

In

stru

ctio

nal

Support

Spec

. kbo

yce

@dad

esch

ools

.net

3

05-9

95

-20

49

DIS

TR

ICT

OF

FIC

E

NA

ME

T

ITL

E

EM

AIL

F

AX

Off

ice

of

Ex

cep

t. S

tuden

t E

du

c.

Mar

y P

az

ES

E I

nst

ruct

ional

Super

vis

or

mp

az@

dad

esch

ools

.net

305-9

95-1

760

Pag

e 3 o

f 5

2013 E

XT

EN

DE

D S

CH

OO

L Y

EA

R A

ND

SU

MM

ER

SE

RV

ICE

S I

NF

OR

MA

TIO

N W

OR

KS

HE

ET

SP

EC

IAL

NE

ED

S M

EA

LS

(D

UE

DA

TE

– M

AY

16 2

014)

C

om

ple

te t

his

pag

e fo

r an

y s

tuden

t w

ith a

dis

abil

ity t

hat

req

uir

es s

pec

iali

zed f

ood p

repara

tion

.

ES

Y/S

UM

ME

R

SC

HO

OL

LO

C #

ES

Y/S

UM

ME

R

SC

HO

OL

NA

ME

ST

UD

EN

T

NA

ME

ST

UD

EN

T

ID

GR

AD

E

(2014-2

015)

SP

EC

IAL

IZE

D F

OO

D

PR

EP

AR

AT

ION

(sp

ecif

y)

Indic

ate

if E

SY

dat

es o

f at

tendan

ce a

re o

ther

than

07/0

7/1

4 –

08/0

1/1

4

Pag

e 4 o

f 5

2013 E

XT

EN

DE

D S

CH

OO

L Y

EA

R A

ND

SU

MM

ER

SE

RV

ICE

S I

NF

OR

MA

TIO

N W

OR

KS

HE

ET

AS

SIS

TIV

E T

EC

HN

OL

OG

Y (

DU

E D

AT

E –

MA

Y 1

6, 2014)

Co

mple

te t

his

pag

e fo

r a s

tuden

t w

ith a

dis

abil

ity t

hat

req

uir

es t

he

tran

sfer

and/o

r co

ord

inat

ion o

f A

ssis

tive

Tec

hn

olo

gy i

n o

rder

to a

cces

s

ES

Y o

r S

um

mer

Ser

vic

es.

Ass

isti

ve

Tec

hnolo

gy t

ran

sfer

s m

ust

be

coo

rdin

ated

wit

h t

he

rece

ivin

g s

chool(

s) a

nd t

he

ES

E S

ervic

e C

ente

r.

Ass

isti

ve

Tec

hnolo

gy t

hat

req

uir

es p

ick

-up f

rom

S&

D m

ust

be

coo

rdin

ated

wit

h t

he

Dis

tric

t E

SE

Off

ice.

N

am

e of

Stu

den

t: __________________

____________________

ID#:

_______________

_______________

Cu

rren

t S

chool

Sit

e: _____________________________________

Mai

l C

ode:

_________________________

ES

Y o

r S

um

mer

Sch

ool

Sit

e: _

_______

_______________________

M

ail

Code:

_

________________________

□ S

um

mer

Ser

vic

es

□

ES

Y S

ervic

es (

da

tes

of

att

end

an

ce i

f o

ther

th

an

07/0

7/1

4 –

08/0

1/1

4_

__

___

____

__

__

___

___

__

)

AS

SIS

TIV

E T

EC

HN

OL

OG

Y

RE

QU

IRE

D

DE

SC

RIP

TIO

N O

FA

SS

IST

IVE

TE

CH

P

RO

PE

RT

Y C

ON

TR

OL

NU

MB

ER

Am

pli

fica

tion S

yst

em

Bat

tery

/Ele

ctri

cal

Acc

ess

Dev

ice

Com

pute

r A

cces

s D

evic

e

Vis

ion E

nhan

ce E

quip

men

t

Voic

e O

utp

ut

Dev

ice

Wri

ting A

cces

s D

evic

e

Oth

er* (

spec

ify)

Pag

e 5 o

f 5

2014 E

XT

EN

DE

D S

CH

OO

L Y

EA

R A

ND

SU

MM

ER

SE

RV

ICE

S I

NF

OR

MA

TIO

N W

OR

KS

HE

ET

EQ

UIP

ME

NT

TR

AN

SF

ER

(D

UE

DA

TE

– M

AY

16, 2014)

Co

mple

te t

his

pag

e if

nee

ded

equip

men

t is

not

avai

lable

at

the

assi

gned

ES

Y /

sum

mer

sch

ool

site

and i

s re

quir

ed f

or

a st

uden

t(s)

to a

cces

s

ES

Y /

Sum

mer

Ser

vic

es.

Equip

men

t tr

ansf

er(s

) m

ust

be

coord

inat

ed w

ith t

he

rece

ivin

g s

chool(

s) i

n c

oll

abora

tion w

ith E

SE

Ser

vic

e C

ente

r

and D

istr

ict

Off

ice.

E

QU

IPM

EN

T T

HA

T N

EE

DS

TO

BE

TR

AN

SF

ER

ED

*

DE

SC

RIP

TIO

N O

F E

QU

IPM

EN

T

PR

OP

ER

TY

CO

NT

RO

L N

UM

BE

R

NU

MB

ER

OF

ST

UD

EN

TS

RE

QU

IRIN

G T

HIS

EQ

UIP

ME

NT

Chan

gin

g T

able

Lif

t

Pri

vac

y S

cree

n

A

dap

tive

Chai

r

Adap

tive

Toil

et

A

dap

tive

Toil

et S

eat

A

dap

tive

Fee

din

g E

qu

ipm

ent

P

rone

Sta

tionar

y S

tand

er

S

upin

e S

tati

onar

y S

tan

der

Posi

tionin

g M

at

O

ther

LO

CA

TIO

N O

F E

QU

IPM

EN

T I

N T

HE

BU

ILD

ING

*

PIC

K-U

P L

OC

AT

ION

SC

HO

OL

NA

ME

AN

D

LO

CA

TIO

N #

PIC

K-U

P L

OC

AT

ION

CO

NT

AC

T N

AM

E

AN

D P

HO

NE

DR

OP

-O

FF

SC

HO

OL

NA

ME

AN

D

LO

CA

TIO

N #

DR

OP

-OF

F

CO

NT

AC

T

NA

ME

A

ND

PH

ON

E

".,1

[f #?

,i3*;

l"Tl1

"'#"1

iff fi

33H

,""

2014

EX

TE

ND

ED

SC

HO

OL

YE

AR

@S

Y)

TR

AN

SP

OR

TA

TIO

N L

IST

]ohP

l.t€t

hisf

ornf

orgl

lstr

d€ni

!who

wiu

E€d

EsY

tn.5

pct!r

iosE

rvie

sa!d

€sig

M!.d

mth

.IEB

4w€I

la.a

nysu

bs€q

ued.

dditi

o!s!

td/o

rgis

ic.s

ubni

tagc

frat

Efo

rln&

I!gE

!L!!h

!ellq

9$i9

e lrd

iost

e w

helh

efth

is i

s a !w

Eq6

t c

r F

visi

@ r

o a

prsv

iors

!€q

u€st

for

.ach

snl

delt

li!6.

R€q

uesb

sub

nitt

d af

q W

edld

rh J

ore2

120l

4 w

iI no

t be

pmt€

ed t

aspd

lrid

m th

c fn

t da

y. B

SY

bu!

rou

ie a

rd s

tude

tt bu

s a$

iglrn

€ot irf

dndi

on w

ill b

€ ew

ilabL

o lh

. S

unm

cr S

choo

l T

ra$p

orta

tior

L m

l{. I

otm

tio m

th.

SS

T s

cr€.

rF w

ill b

€ uD

dal€

d or

! d

lily

b6si

s. I

f lh

er€

erE

any

qu€

stio

s, D

l@.

@t!c

t T

nnsr

,orr

$ion

Nt

305-

23+

3365

.

Frt

com

Dle

ted

form

r to

the

Ite

Dit

of T

rrnD

ort

tiotr

, A

ttn:

M!,

D.n

iie L

€tol

mel

u .t

305-

251{

50 o

r 30

t234

-t02

4 rr

d to

thr

SP

ED

Ser

vtce

CeD

ter

dedg

nrttd

bcl

ow

ofE

SY

Sch

ool:

nt S

choo

l N

ame:

Add

rms

of E

SY

Sch

ool

:w

L#A

.M.B

ELL

:P

.M.

BE

LL:

wL#

Con

toct

Per

son:

Dat

e:

Tel

epho

ne:

paU

Des

igne

e's

Nom

e an

d S

igna

ture

:F

ax:

E&

UA

ELI

EA

dSE

QB

IAIIA

NII9

9E

1 IN

DIV

IDU

AU

ED

S

TO

P W

ITH

OU

T

SU

PE

RV

ISIO

N

2 C

AR

SE

AT

3 R

EG

ULA

R S

ru.

IRA

NS

PO

RrA

TIO

N E

UG

IBIU

TY

1 IN

DIV

IDU

AU

ZE

D

ST

OP

WIT

H S

UP

ER

VIS

ION

5 LI

FT

BU

S W

HE

ELC

HA

IR

WIT

H S

UP

ER

VIS

ION

6 U

FT

AU

S W

'IELC

IAIR

W

ITIIO

UT

S

UP

ER

VIS

ION

7 S

AF

ET

Y V

ES

T (

tND

tV.

ST

OP

Wtr

H S

UP

ER

VT

ST

ON

)

. S

AF

ET

Y B

ELT

IIJN

IQU

E

SE

AT

ING

DE

VIC

ES

A.

ND

ER

EQ

UIR

ED

C.

NR

-CO

ND

ITIO

NE

DB

US

Fax

com

plet

ed l

ist

to T

rans

port

atio

n an

d th

e S

PE

D S

ervi

ce C

ente

r.

Nor

th C

entr

al -

Alfr

edia

Rob

inso

n 30

5-82

7-30

26N

orth

- K

ate

Cad

ieux

Sou

th C

entr

al -

Kat

hy M

agui

re30

5-82

7-30

2678

6-26

8-47

58N

. M

ED

ICA

LEA

UP

ME

NT

O S

ruD

EN

T T

RA

NS

PO

RT

ED

O

UT

OF

SC

HO

OL

DIS

TR

ICT

S.

SH

OR

'ET

VE

D

SC

T'O

OL

DA

Y O

R A

LIE

RN

AIE

S

CH

OO

L D

AY

( T

IME

V.

VO

CA

TIO

NA

US

H,!.

RE

T

IME

PR

OG

RA

M

Sou

th -

Hel

ene C

hait

305-

242-

8433

Cen

terS

choo

l -

Mar

yA. P

az

305-

995-

1760

Cha

rter

Sch

ool

- l(a

ren

Boy

ce

305-

995-

2049

FM

-704

2 R

ev.

(04-

14)

Stu

dent

Nam

e:

Sch

ool-B

ased

Ext

ende

d S

choo

l Yea

r (E

SY

) S

ervi

ces

Log:

201

4

Stu

dent

lD #

:

Sig

natu

re:

(Prin

t N

ame

& T

itle)

ES

Y S

choo

l:

ES

Y F

requ

ency

:

ES

Y S

ervi

ce P

rovi

der:

Cur

rent

Sch

ool:

Dat

e:

ES

Y D

urat

ion

Per

iod:

(Sta

rt d

ate

- en

d da

te)

E =

Ent

ered

Exc

= E

xcus

edE

arly

(tim

e)/ =

Tar

dyX

= A

bsen

tP

C =

Par

ent

Con

tact

*IV

S =

No

sery

ices

bas

ed o

nin

divi

dual

ES

Y f

requ

ency

Tot

al#o

f da

ysin

atte

ndan

ce:_

A

bsen

ces:

D

ayso

f w

eekE

SY

serv

ices

sche

dule

d:tr

M

trT

trW

trR

trF

*Par

ent

Gon

tact

Log

(dat

e, p

urpo

se,

resp

onse

):

Atta

ch o

rigin

alto

the

IE

P a

nd p

lace

in t

he c

umul

ativ

e re

cord

.

Pag

e 1

of2

FM

-657

4 R

ev.

(04-

14)

Stu

dent

:

ES

Y P

artic

ipat

ion

Not

es:

2014

tD #

:

Ser

vice

Pro

vide

r:(N

ame)

(T

itle)

ES

Y s

ervi

ces

are

prov

ided

for

the

mai

nten

ance

of

criti

cal l

ife s

kills

as

docu

men

ted

in t

he lE

P.

The

fol

low

ing

is a

sum

mar

y of

the

IEP

goa

ls d

esig

nate

d fo

r E

SY

ser

vice

s; t

he s

tude

nt's

pro

gres

s (s

tatu

s re

port

) on

the

goal

s an

d pr

ogre

ss t

owar

ds m

aint

enan

ce o

f th

e go

als;

and

the

cla

ssro

om a

ctiv

ities

and

par

ticip

atio

n no

tes.

* S

tatu

s R

eoor

t C

odes

:1,

MA

ST

ER

ED

2.

AD

EQ

UA

TE

PR

OG

RE

SS

4. I

NS

UF

FIC

IEN

TP

RO

GR

ES

S

FM

-657

4 R

ev.

(04-

14)

3. S

OM

E P

RO

GR

ES

S

Pag

e2 o

l 2

Sum

mar

y of

the

Spe

cial

ized

Ins

truc

tion,

Sup

plem

enta

ry,

and/

or R

elat

edS

ervi

ces

as d

ocum

ente

d on

the

stu

dent

's lE

P.

Pre

-Sta

tus

Rep

ort

(5/1

4)*

Pos

t-S

tatu

sR

epor

t (8

/14)

*

Act

iviti

csP

artic

ioat

ion

Not

esW

eek

1

Wee

k 2

Wee

k 3

Wee

k 4

Oth

er _

(s

peci

fy)

Office of HumanProbationary/An n ual Contract

Capital ManagementWaiver Request for Sum mer 2014

TO BE COMPLETED BY SUMMER SCHOOL PRINCIPAL

Instructions: Complete the information below for Probationary/Annual Contract teacher you wish to submit a waiverrequest, sign the form, and scan and email form to PERS@dadeschools.net The teacher must hold a valid

teaching certificate and not have any additional summereligibility lockoutflags (i.e., Certification, META,

Professional Standards) to be considered for waiver. The teacher may not be hired for summerem ployment until approvalfrom Office of Human Resources, Recruiting, Performance Managementand Labor Relations.

Name of Teacher: Employee Number:

Summer Waves of Learning Location Number: Name:

Job Gode: Job Title:

I certify that all eligible instructional staff mem bers from the SummerWaves of Learning site and the feeder schools,who are properly certified and/or are on professional service or continuing contract have been offered summeremployment.

Principal Name/Siganture DATE

Office of Human Capital Management

Instructions: Office of Personnel Actions will review Probationary/Annual Contract teacher for any summereligibilitylockout flags and ensure eligible Professional Services and Continuing Teachers at Summer Waves ofLearning site are exhausted for subject area requested.

Lockout Flags: META(circle flags active for teacher)

CERTIFICATION LEAVE

YES

OPS

All eligible Professional Services and Gontinuing Contract Teachersfor Job Title are exhausted from Summer Eligibility Roster? NO

COMMENTS:

Employment and Staffing

Mariaelena Vidal, Employment and Staffing Officer Date

Return to Office of Personnel Actions to remove PROBATIONARY/ANNUAL CONTRACT Lockout Flag.

SCHOOL CONTACTED: Flaq Removed:

FM Temp. Auth; Exp. Date: Aug 31, 2014

SAP PERIOD #

r-T_l

Week AM

THE SCHOOL BOARD OF MIAMI-DADE COUNTY, FLORIDA

APPLICATION FOR SHORT TERM LEAVE

COST CENTER

PAY PERIOD BEGIN DATE

MONTH DAY YEAR

THE SCHOOL BOARD OF MIAMI-DADE COUNW, FLORIDA

APPLICATION FOR SHORT TERM LEAVE

COST CENTER

PAY PERIOD BEGIN DATE

MONTH DAY YEAR

Week 2 AM PMPM

CHECK

*These codes will interface from "legacy" to SAP, and can g!59 be used on

the "Report Miscellaneous Payroll Transactions" input screen.**These codes will not interface from "legacy" to SAP, and can onlv be used on

the "Report Miscellaneous Payroll Transactions" input screen.

COMMENTS:

I certifv that the above information is correct and in accordancewith the School Board of Miami-Dade County, Florida, policies and

regulations.

EMPLOYEE NAME:

EMPLOYEE SIGNATURE:

CHECK

*These codes will interface from "legacy" to SAP, and can qlgg be used on

the "Report Miscellaneous Payroll Transactions" input screen.**These codes will not interface from "legacy" to SAP, and can gly be used on

the "Reoort Miscellaneous Pavroll Transactions" input screen.

COMMENTS:

I certifv that the above information is correct and in accordance

with the School Board of Miami-Dade County, Florida, policies and

regulations.

EMPLOYEE NAME:

EMPLOYEE SIGNATURE:

PERSON lD or PERS ASSIG PERSON ID or PERS ASSIG

SAP PERIOD

t--T_l

Week 2 AM PM Week AM PMFRI

)Al

SUN

MON

TUE

WED

THURS

FRI

SAT

SUN

MON

TUE

WED

THURS

FRI

SAT

SUN

MON

TUE

WED

THURS

FRI

SAT

SUN

MON

TUE

WED

THURS

ONIY ONE (1) WP E OF IEAVE PER FORM:

TYPE OF TEAVE

Reg.

YearSummer10-MOONtY

PfiHrly

Bus Drvrs.& Bus Aides

ONLY

lllness of Self 0200 0230 0203*

lllness/Death of Relative 0201 0237 0204*

Personal 0282 0232 0205'

Injury at Work (Explain) 0285 0285 0207 0207*

Contagious Disease(Contracted at Work)

0286 0286 0208 0208.

Vacation 0283

Temporary Duty(Explai n)

0287 0287 0209*

LWOP, Auth (Explain) 0400 0400 0403*

LWOP, Unauth (Explain) 0401 0401 0404*

OTHER: 0219*

COMPENSATORY TIME 0284 0284

JURY

DUTY/SUBPOENAED

0288 0288 oz70 02 10*

OPT DAY 0289

ELECTED OFFICIAL 0294 0294 02 15*

MILITARY TRAINING 0296 o296 o2r7**

UNION

REPRESENTATIVE

0290 0290 Q211,

UNION OFFICIAL

BUSINESS

0297 o29r 0272**

UNION POOL DAY 0292 0213*'

oNtY oNE (11 rYF 'E OF LEAVE PER FORM:

TYPE OF LEAVE

Reg.

YearSummer10-MOONtY

PltHrly

Bus Drvrs.

& Bus AidesONtY

lllness of Self 0200 0230 0203*

lllness/Death of Relative 0207 0237 0204'

Persona I 0282 o232 0206*

Injury at Work (Explain) 0285 0285 0207 0207*

Contagious Disease(Contracted at Work)

0286 0285 0208 0208*

Vacation 0283

Temporary Duty{Fxnlain}

0287 0287 0209*

LWOP, Auth (Explain) 0400 0400 0403

LWOP, Unauth (Explain) 0407 0401 0404*

OTHER: o2L9*

COMPENSATORY TIME 0284 0284 0500*

JURY

DUTY/SUBPOENAED

0288 0288 0210 0210*

OPT DAY 0289

ELECTED OFFICIAI. 0294 0294 0215**

MILITARY TRAINING 0296 0296 0217**

UNIONREPRESENTATIVE

0290 0290 021 1*

UNION OFFICIAL

BUSINESS

0297 0291 0272*

UNION POOL DAY 0292 oz92 0213*

PRI NCIPAL/ADMI N ISTRATOR SIG NATU RE

FM-s949(05-12)PRI NCI PAL/ADM INISTRATOR SIG NATURE

FM-s949(06-12)