Employee Name :
Department : Employee ID# :
CHECK ALL BOXES THAT APPLY Family and Medical Leave* Work Related Injury/Illness* Neither
Dates # Hours Dates # Hours
Vacation Sick Leave*
Please Specify:
Vacation in place of Self Family*
Sick Leave Illness/injury
Parental Leave Medical
Organ Donation Leave
Death in Family
Compensatory Time *Relationship
Jury Duty/Court Exposure to Contagious Disease
COTC Personal Leave
Military Leave*
Campus Business
Unpaid Time Off* (10 or fewer consecutive days)
Beginning and Ending Dates # Hours
Unpaid Leave of Absence (more than 10 consecutive working days)
Beginning and Ending Dates # Hours
Last date worked Last day in active pay status Return date
Extension of previous approved leave of absence*
ADDITIONAL INFORMATION: (Reason for absence, etc.)
*Any item followed by an (*) requires appropriate documentation. See reverse for explanation of documentation requirements.
I understand that approval of this request is contingent upon the availability of adequate leave balances. Falsification of this Application for
Leave or of the supporting documentation is grounds for disciplinary action, up to and including dismissal.
Employee Signature: Date:
Supervisor Signature: Date:
Staff absences require only the above signature. Faculty unpaid leaves and faculty paid leaves DUE TO CAMPUS BUSINESS that exceed
ten consecutive work days during an academic quarter require approval by the department, college and Provost or President (below).
Dean/Director or President Signature: Date:
Approved Disapproved Comments:
Person responsible in my absence
Phone #:
In an emergency, I may be reached through Phone #: Email:
1. Payroll Copy 2. Faculty/Staff Copy
Application for Leave
Family and Medical Leave Entitles eligible faculty/staff to 12 work weeks of Check appropriate box when requesting FML.
leave to care for 1) a child following birth/adoption, Requires Medical Certification Statement.
2) a serious personal illness or 3) a seriously ill
family member. May be paid or unpaid.
Work Related Injury/Illness Absence resulting from accidental injury or Check appropriate box when requesting leave. Requires
illness occurring at work. documentation that complies with Ohio Bureau of Worker’s
Compensation. Contact the Office of Human Resources.
Neither Request does not apply to any of the leave
Vacation Time off for personal reasons. Follow department procedures.
Sick Leave Absence due to medical need; personal or Follow department procedures. Medical Certification
immediate family member. Statement may be required.
Vacation in place of sick leave Vacation used for absence due to medical Follow department procedures. Medical Certification
need. Statement may be required.
Parental Leave Time off for Regular employees (75% FTE or Follow department procedures. Medical Certification
Greater) due to birth or adoption of a child. Statement may be required.
Organ Donation Leave Regular employees (75% FTE or greater) who Follow department procedures. Medical Certification
donate an adult kidney or any portion of an Statement may be required.
adult liver or adult bone marrow.
Compensatory Time Time off in lieu of overtime by non-exempt Pre-approval and scheduled by mutual agreement within
staff. agreement within 180 days.
Jury Duty/Court Appearance Excused absence if subpoenaed to serve on Attach copy of subpoena or summons as required.
jury or a witness.
Military Leave Leave of absence without loss of pay for up Attach copy of military orders as required.
31 calendar days or a maximum of 176 hours
a calendar year.
Campus Business Absence from regular work site for work Follow department procedures for reporting absence.
related or professional reasons.
COTC Personal Leave Approved leave for COTC faculty to Follow procedures as outlined in the collective
conduct personal business.
bargaining agreement.
Medical Leave Approved time off without pay for employee’s Check appropriate box. Medical Certification
medical reasons. Statement may be required.
Personal Leave Approved time off without pay for personal Check appropriate box. For personal leave, provide
reasons including to care for immediate family written description of specific nature of leave.
member. Medical Certification Statement may be required to
justify family member’s medical condition.
Unpaid Time Off Approved time off without pay for less than Follow department procedures.
10 consecutive working days.
Unpaid Leave of Absence Approved time off without pay for more than STAFF: Department approves or disapproves unpaid
10 consecutive working days. leave of absence requests. If approved, the department
assures dates are accurate and supporting documentation
is complete, and processes. Employee is responsible
for arranging continuation of benefits with HR.
FACULTY: Unpaid leaves of absence require approval of
the Provost or President. Sick leave and vacation
DO NOT require this approval. An unpaid leave of absence
may not exceed two consecutive years; is granted for no
more than one year at a time; and does not automatically
stop the tenure clock for probationary tenure track faculty.
Extension of Previously For medical and personal leave of absence. Requires up-dated Medical Certification
Approved Leave Medical Certification Statement.
This is not intended as an exhaustive description of policies and procedures governing leave options. For documentation, see HR Policies
and Procedures Manual and collective bargaining agreements for bargaining unit members. Contact the Office of Human
Resources with questions about this form and leave procedures.