Fillable ADMINISTRATIVE LEAVE JUSTIFICATION FORM (Arizona)

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ADMINISTRATIVE LEAVE JUSTIFICATION FORM (Arizona)

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Arizona State Personnel System
ADMINISTRATIVE LEAVE JUSTIFICATION FORM
Agencies are required to submit this form no later than five working days prior to an employee's administrative leave extending beyond 240 working hours
Agency Name
Request Submitted By
Date
Employee Information
Employee Name Employee EIN
Administrative Leave Start Date
Number of Hours Employee Has Been on Administrative Leave
Please provide a detailed description of the reason the employee is on administrative leave
Please provide sufficient justification why the agency is requesting approval to continue this employee on administrative leave in excess of 240
working hours pursuant to State Personnel Rule R2‐5A‐B604. Attach additional pages if necessary.
Please submit this form electronically to: humanresources@azdoa.gov
Employee Status
ASPS/HRD‐FA6.02 4/19
Anticipated End Date (Required)
Agency Information
AGENCY RECOMMENDATIONS
DENIAL APPROVAL
DENIAL APPROVAL
RECOMMENDATION
FOR ARIZONA DEPARTMENT OF ADMINISTRATION USE ONLY
DENIED
APPROVED
Comments
ADOA Deputy Director of Operations
or Designee Signature
Agency Head
Signature
Date
Agency Chief Human
Resources Signature
DETERMINATION
Date
RECOMMENDATION
Date
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ADMINISTRATIVE LEAVE JUSTIFICATION FORM (Arizona)

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Completed 20 July 2020

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