LEAVE REQUEST FORM

LEAVE REQUEST FORM

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)