ࡱ> 9;8 bjbjCC 4"))  $6%&R(zzzziii[%]%]%]%]%]%]%$(*%iiiii% zz%   i zz[% i[%  ry#T1$}4js#G%%0%#VV+ V+1$ 1$>o$iii%% iii%iiiiV+iiiiiiiii * :   THE UNIVERSITY OF NORTH CAROLINA AT PEMBROKE Serious Illness and Disability Leave for Faculty This form is for use by faculty who are requesting leave under the Faculty Handbook policy titled Leaves of Absence and Other Adjustments of Employment Obligations. --------------------------------------------------------------------------------------------------------------------- Section I: EMPLOYEE INFORMATION (To be completed by the EMPLOYEE) 1. Employee Name:__________________________________________________________ (Please Print) 2. Banner ID No.: ________________________ Phone No.:_____________________ 3. Title:________________________________ Department:________________________ 4. Reason for leave request: __________________________________________________ ________________________________________________________________________ [NOTE: A medical certification from the attending physician must be attached. For the employees serious health condition complete  HYPERLINK "http://www.uncp.edu/hr/forms/WH-380-E_FMLA.pdf" FMLA Form WH-380-E (Certification of Health Care Provider for Employee's Serious Health Condition (PDF)  or for an immediate family member complete  HYPERLINK "http://www.uncp.edu/hr/forms/WH-380-F_FMLA.pdf" FMLA Form WH-380-F (Certification of Health Care Provider for Family Member's Serious Health Condition) No request for family medical leave can be approved without medical certification.] 5. Leave request: with pay _____ or without pay ___________ for _________weeks 6. Starting Date:______________ Expected Ending Date:_____________ 7. Employee Signature:______________________________________ Date:______________ Section II: DEPARTMENT CHAIR INFORMATION (To be completed by the Dept. Chair) 1. Name:_______________________________________ Phone No.:_________________ 2. Support: ___ Yes ___ No 3. Signature:___________________________________ Date:_______________________ Section III: DEAN INFORMATION (To be completed by the Dean of the School or College) 1. Name:_____________________________________ Phone No.: ___________________ 2. Support: ___ Yes ___ No 3. Signature:______________________________________ Date:____________________ ________________________________________________________________________________ Section IV: PROVOST AND VICE CHANCELLOR FOR ACADEMIC AFFAIRS Serious Illness and Disability leave is: APPROVED: WITH PAY _____ APPROVED: WITHOUT PAY _____ DISAPPROVED: ____ Signature:__________________________________________ Date:____________________ Return completed form to 鶹P, Human Resources, PO Box 1510 Pembroke NC 28372 Revised 4/2012 -^_x   | % 2 3 4 d  ǴǴ|rlfl`ZTLHh 0jh 0U h|CJ hCJ h$3CJ h}ECJ hNtCJhK5>*CJ\ hC{CJ h<CJ hKCJ$hchQ56CJ\]^JaJ$hchXA56CJ\]^JaJ$hch4Po56CJ\]^JaJ$hcho56CJ\]^JaJ!hQ5B*CJ\^JaJph!h#I,5B*CJ\^JaJphhK-^_ | ! " n o   \  0^`0gdQ$a$gd@&gdqgd#I,$a$gdC{$a$gd#I, $d@&a$gdq@&gdq  Y Z \ q r ˼˟}w}wqwwke hCJ hmCJ hRCJ hQCJ h4^CJ h<CJ hCJ hKCJh}EhQ5CJh}EhK5CJh 0h~ kh|CJaJmH sH h~ kh|CJaJmH sH h|CJaJmH sH #jh 00JCJUaJmH sH h|0JCJaJmH sH jh 0U!IJ:;=FGVXYSlnpKLXz-.·ߦͦߦߠ嚠ٔٔ h|6CJ hqCJ h&Y`CJ hC{CJ hoCJhC{hCJaJhC{hmCJaJhC{hKCJaJ hmCJ hCJ hRCJ hKCJ h4^CJ h<CJh|hmCJaJmH sH 8HI9:WXOPmnM 0^`0$0^`0a$gd4^ &dP&d@&Pgdq@&gdqMN./gdBE``gdR@&gdqgdq 0^`0gdC{ ./~hBE`hKCJaJhqBhBE`CJaJhBE`CJaJ hBE`5CJhqBhBE`5CJ hRCJ21h:p/ =!"#$% *~06666666660@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH >>  Heading 1$@& 5CJ\::  Heading 2$@&5\BB  Heading 3 $@&a$ 5CJ\BB  Heading 4$@& 5>*CJ\DA D Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List 0>@0 Titlea$5\>J> Subtitlea$ 5>*CJ\2B2 Body TextCJ6U`!6 |0 Hyperlink >*B*phH2H 4^ Balloon TextCJOJQJ^JaJN/AN 4^Balloon Text CharCJOJQJ^JaJb/Rb #I,Default 7$8$H$-B*CJOJQJ^J_HaJmH phsH tH 4Yb4 q Document MapB/qB qDocument Map CharCJaJPK!pO[Content_Types].xmlj0Eжr(΢]yl#!MB;.n̨̽\A1&ҫ QWKvUbOX#&1`RT9<l#$>r `С-;c=1g3=KjK爉ŬʉaqHwo?x}>6!N J?6v?w_Z3tç$y/,YVϲYLcDt~q"9⧣E"g 36AxgKA,Ɖڳ=&-䧘"󷡳<+)/騳2YfEA5i5r{F2rhnz*kU̘aby&Z4MtoKnwu[K@Y5Fm3AM2ޕaŨ; uۭ=: ުv|TV_>%^/*!C!=I.pŭG2#=u{A*?xMVfȯ׆h,"N~e /w$wmBTRUzcn5fwЪtq:nT=q k:V=*^&whv3om <"^PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-!pO[Content_Types].xmlPK-!֧6 -_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!Atheme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] " . M Y XXL# @0(  B S  ? KSryU`[f q| 333333333333slbH G ,_8 ^`OJQJo( 8^8`OJQJo(^`OJQJ^Jo(o  p^ `OJQJo(  @ ^ `OJQJo( x^x`OJQJo(H^H`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(uMu^u`Mo(.^`.L^`L.  ^ `.jj^j`.:L:^:`L.  ^ `.^`.L^`L.^`CJOJQJo(^`CJOJQJo(opp^p`CJOJQJo(@ @ ^@ `CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(PP^P`CJOJQJo(808^8`0o(.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.,_slGf E        vjb        b3A])M{Xb3A])M0X,54Q,> K|B#I,$3|6l8L@XA}E$JOPOU4^BE`&Y`Gddd~ k4PoNtC{o;"I%q cR 0Q|qm<l\c 2# @I @UnknownG*Ax Times New Roman5Symbol3 *Cx Arial{BLPBFD+TimesNewRoman,BoldTimes New Roman5.[`)Tahoma? *Cx Courier New;WingdingsA$BCambria Math"h[[C '20 CHP ?Nt2!xx ,THE UNIVERSITY OF NORTH CAROLINA AT PEMBROKEUNCP Mary Cadle     Oh+'0  , P \ h t'0THE UNIVERSITY OF NORTH CAROLINA AT PEMBROKE鶹P Normal.dotm Mary Cadle2Microsoft Macintosh Word@@BE@Zj@Zj ՜.+,D՜.+,d  hp  '鶹 Pembroke  -THE UNIVERSITY OF NORTH CAROLINA AT PEMBROKE Titlet 8@ _PID_HLINKS'A, yG/http://www.uncp.edu/hr/forms/WH-380-F_FMLA.pdfzG/http://www.uncp.edu/hr/forms/WH-380-E_FMLA.pdf  !"#$%&')*+,-./1234567:Root Entry F5j<1Tabler+WordDocument4"SummaryInformation((DocumentSummaryInformation80CompObjr  F Microsoft Word 97-2004 Document MSWordDocWord.Document.89q