GBRHA-E, Application for Sabbatical Medical Leave

FILE: GBRHA-E

Cf: GBRHA

WASHINGTON PARISH SCHOOL BOARD

APPLICATION FOR SABBATICAL MEDICAL LEAVE

UNDER LOUISIANA REVISED STATUTE 17:1170 et. seq.

SABBATICAL MEDICAL LEAVE

IMPORTANT: This application must be sent by certified mail to the attention of the Superintendent not less than sixty (60) calendar days prior to the starting date for which this sabbatical medical leave application is made. Should an applicant become ill during a semester, the request must be sent by certified mail to the attention of the Superintendent no less than thirty (30) days prior to the proposed starting date for the sabbatical medical leave.

Name: ___________________________________

(Last) (First) (Middle I.)

Mailing Address: _______________________________________________________

_______________________________________________________

Social Security Number of Applicant: _______________________________________

List the consecutive semesters of active service in the Washington Parish School System (Ex., 1/94-95 through 2/98-99)

_____________________________________________________________________

Applicant's date of birth: __________________________________________________

Exact period for which leave is requested: ____________________________________

Sabbatical medical leave may only be taken if the applicant has twenty-five (25) or fewer accumulated sick leave days, as of the proposed date the sabbatical is requested to begin. The following must be completed by the Accounting Department of the Washington Parish School System to verify the number of accumulated sick leave days the applicant has, as of the date of the receipt of this application.

The applicant has accumulated sick leave days remaining as of _____________

Verified by: _________________________________________________________

Signature of Accounting Supervisor

Date signed: __________________________________________________________ STATEMENT FROM A PHYSICIAN ATTESTING TO THE NEED FOR THE SABBATICAL MEDICAL LEAVE MUST BE PROVIDED ON THE ATTACHED FORM AND SENT DIRECTLY BY THE PHYSICIAN TO THE WASHINGTON PARISH SCHOOL BOARD.

Please state the exact manner in which the requested sabbatical leave will be spent:

_____________________________________________________________________

I, the undersigned applicant, do hereby acknowledge that, if this sabbatical leave is granted, I will be paid a salary equal to sixty-five percent (65%) of the salary (which is fixed at the inception of the sabbatical leave and will not change during the period of said sabbatical leave) that I would receive if I were employed full-time by the Washington Parish School System at the beginning of the period of this sabbatical leave. I hereby affirm that I will comply with all policies and regulations of the Washington Parish School System and the laws of the State of Louisiana regarding sabbatical leave enumerated in Title 17 of the Louisiana Revised Statutes, as amended.

As a condition of this sabbatical leave and to be eligible for compensation during such leave, I, the undersigned applicant, do hereby agree to return to service in the Washington Parish School System for one (1) semester for each semester of sabbatical medical leave which I may be granted herein, and that such service shall begin immediately at the expiration of the sabbatical medical leave period herein requested.

I further acknowledge that I am prohibited during the period of this sabbatical leave, if granted, to be employed gainfully for more than twenty (20) hours per week, unless such work meets all of the requirements of Louisiana Revised Statute §17:1177, and has been approved by the Board of the Washington Parish Public School System. I further acknowledge that I am prohibited by state law [La. Rev. Stat. Ann. §17:1177(C)] from being employed during the period of this sabbatical medical leave, if granted, by any public or non-public school system within the United States of America, its territories, or possessions.

I further affirm that all statements and representations made herein are true, accurate, and correct to the best of my knowledge and belief.

____________________________________________________________________Applicant's Signature

Date of Completion of this Form

WASHINGTON PARISH SCHOOL BOARD

P. 0. BOX 587

FRANKLINTON, LOUISIANA 70438

504-839-3436

SABBATICAL MEDICAL LEAVE PHYSICIAN'S STATEMENT

AS REQUIRED BY LOUISIANA REVISED STATUTE 17:1170 et. seq

THE INFORMATION CONTAINED IN THIS DOCUMENT IS EXEMPT FROM THE PUBLIC RECORD LAWS OF THE STATE OF LOUISIANA.

PLEASE PRINT OR TYPE

Name of patient: _______________________________________________________

Exact period for which leave is requested: ____________________________________

Name and address of physician: ___________________________________________

__________________________________________

Physician's phone number: ( )__________________________________________

Please complete the following request for information by circling the yes or no and providing a brief response, if appropriate:

Have you examined and/or treated this patient during the past two years?

Yes No

Current diagnosis and date of said diagnosis:_______________________

__________________________________________________________

Based on your current diagnosis:

(a)

Would this condition be considered within the parameters of a contagious or communicable disease?

Yes No

(b)

Would this condition normally cause the patient to be hospitalized?

Yes No

(c)

Is recuperation from the effects of this condition possible?

Yes No

(d)

Does this condition reduce the patient's capabilities in the following areas?

(1)	Vision	Yes No
(2)	Hearing	Yes No
(3)	Speech	Yes No
(4)	Motion	Yes No

(e)

Does this condition prohibit the patient from conducting normal cognitive processes?

Yes No

(f)

Would this condition prohibit the patient from conducting the duties of a teacher?

Yes No

If Yes, then estimate the number of weeks [from the date of the diagnosis] that the teacher would be unable to perform the duties of his/her profession.

weeks

(g)

Based on your diagnosis, could this patient be gainfully employed in any other job or occupation on a part-time basis (20 hours a week or less) during the period of this sabbatical medical leave?

Yes No

Please provide any other information which you feel would be pertinent in the School Board's decision process, as to whether or not to grant the sabbatical medical leave request made by the patient.

_____________________________________________________________________

I, the undersigned, hereby affirm that I am a physician licensed under the laws of the State of Louisiana (or the state of domicile, if different from Louisiana). I further certify, under penalty of criminal prosecution [La. R.S. 14:125], that I have examined the herein named patient/applicant for sabbatical medical leave sabbatical and have found that the medical condition stated above makes the leave applied for herein medically necessary.

_____________________________________________________________________

Signature of Physician (ORIGINAL SIGNATURE ONLY - NO FACSIMILE)

_______________________________

Date Signed

PLEASE MAIL THIS FORM DIRECTLY TO THE WASHINGTON PARISH SCHOOL BOARD OFFICE AT THE ADDRESS GIVEN ABOVE.

WASHINGTON PARISH SCHOOL BOARD

APPLICATION FOR SABBATICAL LEAVE

UNDER LOUISIANA REVISED STATUTE

17:1170 et. seq.

PROFESSIONAL AND CULTURAL IMPROVEMENT

IMPORTANT: This application must be sent by certified mail to the attention of the Superintendent not less that sixty (60) calendar days prior to the starting date for which this sabbatical leave application is made. Those applications received less than sixty calendar days before such date may be denied.

Name:_____________________________________________________________

(Last) (First) (Middle I.)

Mailing Address:_____________________________________________________

______________________________________________________

List the consecutive semesters of active service in the Washington Parish School System (Ex., 1/94-95 through 2/98-99)

_____________________________________________________________________

Applicant's date of birth: _________________________________________________

Exact period for which leave is requested: ____________________________________

Complete the following: __________________________________________________

Name and location of College or University to be attended:

_____________________________________________________________________

Name of course(s) of study to be pursued, whether those course(s) are at the graduate or undergraduate level, and the number of semester hours of each:

_____________________________________________________________________

If a formal course of study at a college or university is NOT contemplated, please describe the program of independent study, research, authorship, or investigation which will be pursued.

_____________________________________________________________________

If travel, rather than a course of formal study, is planned, state how such travel will be of educational value in directly improving your skills as a teacher.

_____________________________________________________________________

Please state and specifically describe below how the course of study or travel listed above will enhance your teaching skills.

_____________________________________________________________________

I, the undersigned applicant, do hereby acknowledge that, if this sabbatical leave is granted, I will be paid a salary equal to sixty-five percent (65%) of the salary [which is fixed at the inception of the sabbatical leave and will not change during the period of said sabbatical leave] that I would receive if I were employed full-time by the Washington Parish Public School System at the beginning of the period of this sabbatical leave. I grant permission and/or authority to the institution(s) named in this application to release my school attendance, courses undertaken, grades earned therein, and any other relevant information to officials of the Washington Parish Public School System. I further attest and authorize that a photocopy of this application may be considered as an original for purposes of requesting the release of information to the Washington Parish Public School System.

As a condition of this sabbatical leave and to be eligible for compensation during such leave, I, the undersigned applicant, do hereby agree to return to service in the Washington Parish Public School System for one (1) semester for each semester of sabbatical leave which I may be granted herein, and that such service shall begin immediately at the expiration of the sabbatical leave period herein requested.

I further acknowledge that I am prohibited by state law [La. Rev. Stat. §17:1177(C)] from being employed part-time or full-time during the period of this sabbatical leave, if granted, by any public or non-public school system within the United States of America, its territories or possessions.

I further affirm that all statements and representations made herein are true, accurate and correct to the best of my knowledge and belief.

____________________________________________________________________

Applicant's Signature Date of Completion of this Form

Washington Parish School Board