Name:
College ID#
Department:
Date:
Date Time In/Out
Date Time In/Out
Date
Date
Comp Time Worked
Non-Exempt Only
Prev. Balance: ( )
Worked: ( ) New
Balance:
( )
/
/
Other Leave
Military Duty
Jury Duty
Faculty Personal Day
Birthday Holiday
/
/
Bereavement Leave
Sick Leave
Vacation
Relationship: ( )
*Sick Leave
Submit within 3 days of
returning to work
FMLA
FMLA Intermittent
Vacation Leave
Please use one line for each date of absence and return form to HR.
HR Use Only
Total Hours
INSTRUCTIONS
This form is to be completed to request leaves of absence,
sick leave and overtime. All leave and compensatory time
request (except for illness) must be preapproved and
submitted to your supervisor before the leave is taken or
compensatory time is earned/used. For vacation and sick
leave requested, specify the date and hours taken. For
compensatory time specify the date, time and hours
worked/used.
NOTE According to the O.R.C. 124.18(A) a non-exempt
(hourly) employee may only accrue 240 hours maximum
compensatory overtime within 180 days of being granted.
Date
Comp Time Used
Non-Exempt Only
Prev. Balance: ( )
Worked: ( ) New
Balance: ( )
/
/
/
/
Other Approval
Please contact Human Resources at Ext. 7834 for all
other types of request.
EMPLOYEE LEAVE REQUEST FORM
Type of Leave
Total Hours
Total Hours
*More than 3 consecutive work/contract days will be applied to your FMLA accumulated 12 weeks in one-year period, if it is a qualifying FMLA leave unless proven
otherwise at a later date.
Employee Signature
Date
Supervisor Approval
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