LEAVE REQUEST FORM
________________________________________ ______________________________________
Employee Name Department/ Division
TYPE OF LEAVE
|
BEGINNING MO/DAY/YR HOUR |
ENDING MO/DAY/YR HOUR |
TOTAL HOURS |
ANNUAL LEAVE (Request in Advance)
|
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SICK LEAVE*
|
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COMPENSATORY LEAVE** (Request in Advance)
|
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LEAVE WITHOUT PAY (Request in Advance)
|
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OTHER______________ (See current leave policy)
|
_________________________________ ____________
Employee’s Signature Date
APPROVED:
_______________________________ ___________ _________________________________ ____________
Supervisor’s Signature Date Provost/ Dean/ Division or Dept. Head/ Date
Vice Chancellor’s Signature
_________________________________ ____________
**Provost/ Vice Chancellor/ Chancellor’s Date
Signature
*A physician’s statement or other acceptable proof may be required after three consecutive days of sick leave.
**The Provost, Vice Chancellor or Chancellor’s signature is required for use of compensatory leave (applies to unclassified staff/administrators).
Form 2400/001 (5/03)