Fillable LEAVE WITHOUT PAY (LWOP) REQUEST FORM DATES OF (Boise State University)

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LEAVE WITHOUT PAY (LWOP) REQUEST FORM DATES OF (Boise State University)

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LEAVE WITHOUT PAY (LWOP)
REQUEST FORM
Note: A request for LWOP must be approved in advance. All vacation and compensatory time (if applicable) must be exhausted prior to
LWOP commencing. Any LWOP absence may affect medical premiums and/or eligibility for health insurance. Do not use this request for
Family Medical Leave absences.
EMPLOYEE: __________________________________ TITLE: ________________________________ Employee ID: _________________
(please print)
DEPARTMENT: ____________________________________________ EXT: ____________________________ MS: _________________________________
DATES OF REQUESTED LEAVE
Structured Time Off
From __________ months
__________ hours per week
To __________ months*
__________ hours per week*
Start Date: _____________
End Date: _______________
OR
Sporadic Time Off
______ Days per year*
or
______ Hours per year*
Provide schedule of dates for unpaid absences
JUSTIFICATION (To be completed by employee - please provide reasons for request):
SUPERVISOR SECTION
Please provide details on how work will be accomplished is leave is approved:
APPROVAL SECTION
______________________________________________________________________________________ [ ] Approved [ ] Disapproved
Supervisor (print name and sign) Title
______________________________________________________________________________________ [ ] Approved [ ] Disapproved
Dean/Director (print name and sign)
______________________________________________________________________________________ [ ] Approved [ ] Disapproved
Human Resource Services Rep (print name/sign) Title
Instructions: Forward completed request to HR once supervisor/Dean/Director have authorized for processing. HR will disburse final request action to:
cc: Employee, Supervisor, Dean/Director, HR (Benefits & Employee Record) Rev: 5-19-10
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LEAVE WITHOUT PAY (LWOP) REQUEST FORM DATES OF (Boise State University)

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Completed 17 August 2020

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