Date Date
Revised 2/11/2016
CONNORS STATE COLLEGE
RECORD OF LEAVE
_____________________________ _______________________________
Name of Employee Employee CWID
_________________________________ ______________________ ________________________
Department Department # Supervisor
Approval is requested as follows: Total Leave:
Beg
inning _______________________ ______________________ Days____________________
Thr
ough _________________________ ______________________ Hours___________________
Sick Leave (Absence due to personal illness).
Special Sick Leave: Relationship:____________
Family Medical Leave Act (FMLA) Relationship:____________
Compassionate Leave (See Faculty & Staff Handbook for Definition) Relationship:____________
Personal Circumstances Leave (Deducted from sick/annual leave-See Faculty and Staff
Handbook-Only absence required by emergency business or inclement weather not to exceed
two days per year.)
Annual/Vacation (Eleven and twelve month employees with prior approval of supervisor.)
COMP Time
Administrative Leave
Workmen’s Compensation
Leave Without Pay (Please explain) Reason:__________________________________________
_______
_________________________________________________________________________
________________________________________________________________________________
_______
_________________________________ ______________________________________
Signature of Employee Signature of Supervisor
_______
_________________________________ ______________________________________
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