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COAHOMA COMMUNITY COLLEGE (Coahoma Community College)

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COAHOMA COMMUNITY COLLEGE
EMPLOYEE LEAVE REQUEST
TWO WEEKS OR LONGER
Name________________________ Position _________________ Date of Request __________________
Department___________________________ Supervisor _______________________________
Date(s) Leave Beginning _____________________________ Ending ___________________________
Type of Leave: (check One)
( ) FMLA
Maternity [ ]
Adoption [ ]
Spouse, son or daughter, or parent [ ]
Medical Leave [ ]
( ) Indefinitely Leave
( ) Personal
( ) Military Leave
( ) Sick Leave [ ] One Week [ ] Two Weeks [ ] One Month or Longer
( ) Worker’s Compensation
( ) Educational Leave [ ] 4 to 6 Weeks [ ] 3 to 6 Months or Longer
( ) Leave without Pay [ ] One Week [ ] Two Weeks [ ] One Month or Longer
Was there a written request for leave? ________________ If so, please attach. If not, has the employee
been notified of the college’s leave policy? Yes______ or No______ Date Employee Will Return From
Leave _____________________________________.
Employee ___________________________ Date _________________________
Dean/Director ________________________ Date _________________________
Business Manager___________________ Date _________________________
President ________________________ Date _________________________
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COAHOMA COMMUNITY COLLEGE (Coahoma Community College)

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Completed 19 September 2020

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