LeaveOfAbsenceRequest

The document is a Leave of Absence Request form for employees of the New York City Housing Authority. It outlines the necessary information required for requesting leave, including employee details, type of leave, and approvals needed for leaves exceeding 30 days. Additionally, it specifies conditions for advance vacation pay and the requirement for supporting documentation in certain cases.

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LeaveOfAbsenceRequest

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Sze Chan

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NYCHA 015.015 (Rev. 6/06)

LEAVE OF ABSENCE REQUEST NEW YORK CITY HOUSING AUTHORITY
EMPLOYEE INFORMATION
EMPLOYEE'S NAME (Print) EMPLOYEE ID # DATE

EMPLOYEE'S TITLE DEPARTMENT/DIVISION OR DEVELOPMENT

If requesting a leave of absence over 30 calendar days, you must provide your address and telephone number.
HOME ADDRESS CITY STATE/ZIP TELEPHONE #

( )
REQUEST
ANNUAL LEAVE N U M B E R O F WORKING FIRST DAY AND HOUR LAST DAY AND HOUR
LEAVE Days Hours OF ABSENCE OF ABSENCE

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BALANCE AS OF 1ST
DAY OF ABSENCE REQUESTED

Annual Leave shall be taken at the convenience of the Authority. If the interests of the Authority so dictate, any absence may be investigated
and corroborating evidence may be required. For leave of more than 30 calendar days because of illness or childcare, supporting
documentation must be attached.
I hereby request a leave of absence for the reason(s) stated below. Describe in detail and attach supporting documentation if required.
WITH PAY AND/OR WITHOUT PAY EXCUSED

ANTICIPATED LEAVE – I hereby request __________ days of leave with pay in anticipation of leave to be earned in the future.
If approved, I understand that beyond my approved anticipated leave, ALL future absences will be pay docked until the amount is
repaid in full. In order for this request to be considered, I have attached the Health Care Certification (NYCHA 015.216) with my
treating physician's original signature affixed.
ADVANCE VACATION PAY – This request must be submitted at least 30 calendar days before the vacation begins. An advance
of up to four weeks vacation pay may be given only if there is an equal amount of accrued leave available.
I hereby affirm that during the entire period of leave of absence without pay, I will not be employed outside the New York City
Housing Authority. I hereby certify that I have sufficient leave to cover this advance vacation pay request.
EMPLOYEE'S SIGNATURE DATE

APPROVALS
ADVANCE VACATION PAY REQUEST
APPROVED I hereby certify that the employee has sufficient leave time for the requested advance vacation pay.
DISAPPROVED I hereby certify that the employee has insufficient leave time for the requested advance vacation pay.
SUPERINTENDENT (Print & Sign) (where applicable) DATE

DIVISION CHIEF OR HOUSING MANAGER (Print & Sign) (where applicable) DATE