Los Medanos College Faculty Request for Leave
Employee (Print Name) Employee Signature
Department Date
Type of Leave:
(Check appropriate box)
Conference or Meeting - (Request must have approval at least one week in advance)
Approved for Individual Variable FLEX Credit, if applicable. Dean’s Initials ___________
Full-Time: All contractual obligations on a given day must be completed by the faculty member before any activity can
be considered for Variable Flex credit.
Adjunct: Eligible during non-classroom or office hour time.
Attendance at professional meetings, conferences or other professional activities
Sponsoring Organization:
Location:
Purpose of Meeting, Conference or Activity:
Personal Necessity
Sick Leave
Regular Sick Leave Extended Sick Leave Family Sick Leave
Other Leave
Family Bereavement Leave Military Leave
Judicial and Official appearances when subpoenaed Religious Leave
Authorized Leave Without Pay Industrial Leave
Scheduled Dates
Date or
Week
Time
Total Number
of Hours
Date or
Week
Time
Total Number
of Hours
Check all that apply: Classes will be Cancelled Held Substitute(s) Required Not Applicable
If cancelling list classes which are cancelled: If substitute instructor(s) required, list who & which classes:
