Alabama A&M University Request and Application for Leave Form
Office of Human Resources Rev. June 2015
REQUEST AND APPLICATION FOR LEAVE
Date: Name:
Department: A-Number:
Purpose
(Required for the following leave: Sick, Family
Emergency, Funeral, and Leave Without Pay)
Leave without Pay
(Less than 1 pay period.)
FMLA
3
with Annual Leave
(MUST Submit Copy to HR)
FMLA
3
with Sick Leave
(MUST Submit Copy to HR)
FMLA
3
with Leave without Pay
(MUST Submit Copy to HR)
Court/Jury Duty
(Leave with pay)
Attach copy of Summons or Subpoena
Military Leave
(Leave with pay up to 21 days or 168
hours. After 21 days/168 hours, leave
without pay.)
Attach copy of orders
1
Paid sick leave and paid family emergency leave may be granted in accordance with approved policy and procedures. Sick leave must be accrued before it can be
used. Eligible employees may be granted Sick Leave when they are unable to perform their duties because of personal illness or injury, or illness within their
immediate family, or because they must be absent from work for the purpose of obtaining health-related professional services which cannot be obtained after regular
working hours. The University defines immediate family as: spouse, spousal equivalent, children, step-children, children-in-law, parents, step-parents, parents-in-
law, brothers, brothers-in-law, sisters, sisters-in-law, grandparents, grandparents-in-law, grandchildren, aunts, uncles, nieces, nephews; and first and second cousins.
A supervisor, or the employee’s department head, may require at any time that a claim for sick leave be supported by adequate documentation.
2
Full time and regular staff members who are in active work status (e.g. regularly reporting to work at the time of the request for leave) shall, upon written request,
be granted up to three (3) days of bereavement leave for the death of an immediate family member. The University defines immediate family as: spouse, spousal
equivalent, children, step-children, children-in-law, parents, step-parents, parents-in-law, brothers, brothers-in-law, sisters, sisters-in-law, grandparents, grandparents-
in-law, grandchildren, aunts, uncles, nieces, nephews; and first and second cousins.
3
FMLA (Family Medical Leave Act) is granted in accordance with approved AAMU Procedure 6.7. An eligible employee may take up to 12 weeks of FMLA leave
in a rolling 12-month period. An employee must use any accrued annual and sick leave during an approved FMLA leave. If an employee’s accrued annual and sick
leave is exhausted but the employee is still eligible for additional leave under the FMLA, the remainder of the employee’s FMLA leave will be unpaid. The office of
Human Resources must approve all FMLA leave.
I, the undersigned Employee, certify that the above leave was taken or will be taken in accordance with Alabama A&M University Leave policies
and procedures. I understand that failure to adhere to institutional leave policies and procedures may result in discipline up to and including
termination.
Employee Signature Date Supervisor Date
Alabama Agricultural and Mechanical University
Office of Human Resources
Mailing Address: Human Resources, Alabama A&M University, Normal, AL 35762
Phone: 256.372.5835 Fax: 256.372.5881
