LEAVE OF ABSENCE REQUEST FORM
EMPLOYEE NAME ID#
LEAVE CODES
VAC Vacation
PER Personal
SIC Sick (An illness or injury to self or immediate family member)
FUR Furlough
BRV Bereavement (three days maximum)
JRY Jury Duty (provide copy of summons or subpoena)
OTH Other (provide explanation)
Leave Code Start Date End Date # Hours Used
Check Yes if Applies
to FMLA*
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Note: Support Staff must record this information on their timecards.
Employee Signature/Date Supervisor Signature/Date
Please forward the Original Signed Copy to Payroll for processing.
Refer to the Paid Leave Policy 5.30 & Leave of Absence Policy 5.35 for complete details.
Sick Leave may be used for reasons of personal illness, injury, or medical appointment of an employee and/or to care for an illness or injury or to
attend to a medical appointment of an immediate family member. Immediate family members include the employee’s spouse, children, step-
children, foster children, children for which the employee is a legal guardian, employee’s parents, step-parents and foster parents.
Bereavement Leave - Up to three consecutive working days of leave with pay will be granted to regular, full-time employees upon the death of a
family member. Please refer to Paid Leave Policy 5.30.9 for definition of family members.
*FMLA must be approved by Human Resources. Please refer to the FMLA Policy 5.44
for qualifying FMLA leave.
Select Relationship
Select Relationship
Select One
Select One
Select One
Select One
Select One
Select One
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