CCI Leave Of Absence (LOA) Request Form

§ 9876.5 (a) The DUI program shall require the participant to request a leave of absence whenever the participant is unable to attend any scheduled program activities for 21 days or longer. Participants may request a leave of absence for less than 21 days.

§ 9876.5 (b) To request a leave of absence, the participant shall submit to the DUI
program a written request for leave of absence, and any documentation
substantiating the need for a leave of absence. The written request shall specify the following information below.

Please state what documentation you will be emailing to cascadecircle@cascadecircle.net*

NOTE: We cannot approve most LOA's without documentation. Call office during business hours or email if you have any questions. 530-222-8302/cascadecircle@cascadecircle.net

Name*

First NameLast Name

Email

example@example.com

Date you need LOA to begin: *

Begin Date

Date you will return to the program:*

Return Date

§ 9876.5 (c) The DUI program shall require the participant to request prior approval for all leaves of absence, unless unable to do so due to circumstances beyond the participant's control. If the participant requests retroactive approval for a leave of absence, in addition to the information listed in Subsection (b) of this
section, the request for leave of absence shall explain the circumstances that
prevented the participant from requesting prior approval.

§9876.5 (e) The DUI program director/administratoror designee shall approve a leave of absence only for one of the following.*

Military personnel whose orders or responsibilities require an extended absence.Participants whose work requires travel for an extended period of time;Participants who are absent due to their own extended illness or medical treatment or that of a family member;Participants who are incarcerated or participating in a residential alcoholism or drug abuse recovery or treatment program;Participants who cannot participate in program services due to an extreme personal hardship or family emergency. The DUI program shall document in the participant's record the nature of the personal hardship or family emergency;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 DUI program in accordance with the participant's ability to pay, pursuant to Section 9878 and 9879, prior to the leave of absence.

PLEASE NOTE: The above 6 choices are the ONLY allowable reasons for a LOA to be considered. If your request does not fall into one of these categories then the program cannot approve your request.

What is the reason you are requesting a Leave of Absence?*

Please give as much detail as possible.

§9876.5 (f) Prior to program completion, the DUI program shall require the participant to make up all scheduled program activities missed while on a leave of absence.

§9876.5 (g) Time missed while on a leave of absence shall not be counted as participation time.

§9876.5 (d) The DUI program administrator or designee shall review the request.

Any other details you would like to share at this time?

I understand the following:

This is just a LOA request that must be approved by the program in accordance with the Title 9 State Regulations. I must attend my program until I am approved to avoid absences or possible termination of my program.
I must email or bring in verification as requested for my LOA to be approved.
If I do not ATTEND a session within 21-days of my return date above I will be terminated from the program for failure to attend. If I need to change my dates for any reason I must contact the office and discuss this for approval.
A LOA is not active time and cannot be made up, it will prolong my time in the program.
I have read in full all the information in this document and understand that I will be contacted via email once my LOA has been reviewed. This may take up to 3 business days.
If I have questions I can email cascadecircle@cascadecircle.net or call during business hours 530-222-8302.
Phone hours: Mon-Thurs. 9-5 (Lunch 12:00-1:00) Friday 9:00-12:00
I understand there is an $25.00 charge for a LOA.

Client Signature

Date of Request

Date

Documentation Attached: ____________________________________

Authorized Signature Approving LOA: _____________________________________

Date Approved:_______________

Email approval or denial attached _________