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
for jury duty beginning on .
(month) (date) (year)
Name of employee (please print)
_____ 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
DISTRICT OFFICE USE ONLY
Notification received (date)