THE NEW YORK CITY DEPARTMENT OF EDUCATION
DIVISION OF HUMAN CAPITAL - HR CONNECT
MEDICAL, LEAVES AND RECORDS ADMINISTRATION
65 Court Street, Brooklyn, NY 11201
Request for Leave of Absence for a 9/11-Related Illness Form
TO BE COMPLETED AND SIGNED BY EMPLOYEE:
Employee's First Name
Home Address
Work Location
Borough
Location
Code
Home Telephone
Work Telephone
to
Comments
DateSignature of Employee/Beneficiary
Work Address
City State Zip
City
Zip
Employee's Last Name
Work Email
State
District
from
Title
Active Employee
Retiree
Choose one: Are you a(n):
I hereby request a Leave of Absence:
Intermittent
Continuous
1. As of October 23, 2018, were you in an active status with NYC Department of Education or another City Agency?
Yes - in active status with NYC DOE
amounting to
period of time.
Request for Leave of Absence for 9/11-Related Illness Form
EIS #
Vested Employee
Beneficiary of an Eligible Employee
EMPL ID #
No
Yes - in active status with another City Agency
2. Have you filed a Notice of Participation with your Retirement System?
Yes
No
If yes, please indicate the Retirement System here:
3. Have you obtained a diagnosis confirming that you have a 9/11-related illness from medical doctors in the
World Trade Center Health Program's Center of
Excellence?
Yes
No
4. Have you previously taken a leave of absence that was related to your 9/11-related illness? If you are a beneficiary of an employee, indicate any dates that the
employee took as a result of a 9/11-related illness.
Yes
No
If yes, please enter the dates of your previous leaves of absence:
Submit this completed form along with your supporting documentation to HR Connect via email: HRConnectLeavesFax@schools.nyc.gov.
In the subject line, please include "9/11 Sick Leave."
