Leave of Absence Instructions
1. Those who cannot attend scheduled OHS activities (Group, Education or Face to Face) for three weeks or longer will need a Leave of Absence to stay current in the program.
2. All reasons for Leave of Absence (LOA’s) must comply with Title Nine (9) Section 9876.5. We will only approve a leave of absence for the following reasons:
(a) Military personnel whose orders or responsibilities require an extended absence;
(b) Participants whose work requires travel for an extended period of time;
(c) Participants who are absent due to their own extended illness or medical treatment or that of a family member;
(d) Participants who are incarcerated or participating in a residential alcoholism or drug abuse recovery or treatment program;
(e) Participants who cannot participate in program services due to an extreme personal hardship or family emergency. The program shall document in the participant's record the nature of the personal hardship or family emergency; and
(f) Participants who have requested a leave of absence for a vacation. A leave of absence shall be granted for a vacation only if the participant has made up all absences and paid all outstanding fees, assessed by the program in accordance with the participant's ability to pay, pursuant to Section 9878(a), prior to the leave of absence.
3. You can request a Leave of Absence with a written request for an LOA and must fully complete the Leave of Absence form ensuring your signature is on the form. The request must contain the date first missed, expected return date and the reason for LOA. You must also submit any documentation substantiating the need for a leave of absence.
4. LOA’s are supposed to be set up in advance. LOA’s that are not set up in advance will also require an explanation as to why the LOA was not requested prior to the leave.
Completing the LOA Form:
1. Please read the entire form before filling it out.
2. Fill in the entire top portion of the form, including your current mailing address.
3. The start date for the LOA is the date of the first activity you will miss. Do not forget to include the date of your return. Estimate the date if you are not sure since LOA’s cannot be processed without an end date.
4. Check off the appropriate box for the reason for the LOA. You must include and explanation for any personal hardship LOA.
5. Leave the “Please contact” section blank
6. Sign and date where it says, “Participant Signature”. Do not fill in any spaces below this section.
7. Mail or fax the completed form with any documentation to the OHS DUIP you are enrolled in.
8. Call the program the next day to ensure that the LOA request has been received and accepted.
See Form Below
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OCCUPATIONAL HEALTH SERVICES
LEAVE OF ABSENCE (LOA) REQUEST FORM
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Client Name: ______Date: ______
Address: ______OHS ID # ______
______OHS Group #______
I am requesting a Leave of Absence (LOA) and understand the time out on Leave of Absence is not counted as active time in the program.
The date of first activity I will miss is on ____/____/____ and I will return on: ____/____/____
Total number of days out of the program is ______. I am requesting the LOA because of:
□ Vacation → only granted to clients who are current in all areas, including program fees.
□ Military Duty □ Work out of Town □ Illness □ Incarceration / Treatment □ Personal Hardship
Explanation for personal hardship: ______
Important Participant Information
· Participant must provide written documentation that support LOA request, (i.e.) reason and dates.
· Participant must contact OHS if the reason for the LOA ends early or needs to be extended.
· When returning from LOA the participant is required to attend a scheduled LOA appointment to be reassigned to remaining program activities:
o Please contact ______@ ______.
· Participants who fail to attend the scheduled LOA return appointment will accrue an absence and may be dismissed for exceeding the number of allowable absences or for 21 days of non-attendance.
12 Hour Program / 3 Month Program / 6 Month Program / 9 Month Program / 12 Month Program / 18 Month Program / 30 Month Program2 Absences / 5 Absences / 7 Absences / 7 Absences / 8 Absences / 10 Absences / 15 Absences
· Participants who require an extension must contact the LOA counselor 24 hours before the scheduled LOA return date.
Participant Signature: ______Date: ______
______OHS Use Only Below This Line______
OHS Staff Signature: ______Date: ______
Documentation: □ is provided □ will be provided upon return.
Fees are: □Current □ Past Due $______Finance Arrangement(s): ______
Based on the above review, the participant’s request for LOA is:
□ LOA Approved □ LOA Conditionally Approved (documentation is needed) □ LOA Denied
CAPA Designee: ______Title: ______Date: ______
LOA extension is approved from: ____/____/___ to: ____/____/___, additional number of days is ____. Documentation for the extension has been received, LOA reason is the same and client has paid LOA fee. CAPA Designee Signature: ______Date: ______