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Series 405.3P - Jury Duty Pre-Approval

Adopted: December 1977
Revised: August 2012

The employee must complete this form and sent it to the Payroll Department within three days of receiving a jury duty notice.

Note:  When an employee returns to work after jury duty is completed, he or she must submit an employee absence report with a certificate from the county stating the number of days and dates served.  If applicable, a deduction will be made on the next paycheck.

          I hereby give notice of my absence from work to participate in jury duty


          service.  Attached is a copy of the request I received from                                 

                                                                                                  (county court)

          for jury duty beginning on                                        .

                                                   (month)       (date)  (year)


Name of employee (please print)                                                                              

Employee classification: 

          _____ Administrator                                         _____ Food Service

          _____ Building Chief                                               Non-licensed Specialist

          _____ Bus Driver/Chaperone/Crossing Guard    _____ Special Staff

          _____ Clerical                                                  _____ Teacher/Nurse

          _____ Custodial                                               _____ Vehicle Technician


Signature of employee                                                       Date                              

Signature of principal or supervisor                                   Date                              


Notification received                                   (date)

__________________________________Payroll Department