PERSONAL LEAVE OF ABSENCE REPORT
Name: Date Submitted:
Length of Leave:
Days:
Hours:
(If less than 8 hours)
Indicate Reason for Absence:
Personal Illness:
Was a physician consulted?
Yes No
Family Illness Military Leave
Dentist Jury Duty
Personal Day Vacation
Other:
Leave without pay:
Professional Development:
Where?
What?
FOR FACULTY USE: If classes are missed, provide following information:
Classes Missed Arrangements
Employee Signature
Supervisor Approval Date Received
SEND COMPLETED FORM TO HUMAN RESOURCES
First Date of Leave: Last Date of Leave:
Print Form