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)

     

    		     

     

    SICK LEAVE*

     

     

    		     

     

    COMPENSATORY LEAVE**

    (Request in Advance)

     

    		     

     

    LEAVE WITHOUT PAY

    (Request in Advance)

     

    		     

     

    OTHER______________

    (See current leave policy)

     

    		     

     

     

     

                 _____________________________________  ____________

    Employee’s Signature       Date

     

           APPROVED:

     

       ______________________________________  ____________

                      Immediate Supervisor/Department Head     Date

                   

               

     

       ______________________________________  ____________

     ** Dean/ Executive Dean/ Assistant Vice Chancellor/   Date

     Vice Chancellor or Chancellor’s Signature

     (as appropriate)

     

     

    *A physician’s statement or other acceptable proof may be required after three consecutive days of sick leave.

    **The signature of an Executive Dean, Dean, Assistant Vice Chancellor, Vice Chancellor or Chancellor’s signature (as appropriate) is required for use of compensatory leave (applies to unclassified staff/administrators).

     

     

    Form 2400/001 (8/11)  

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