MSU DENVER Leave/Absence Request and Authorization
Any medical information is confidential and must be kept in separate files with limited access.
Name: MSU DENVER ID:
Department & Division: Work #:
I understand that leave must be requested and approved in advance, where foreseeable. I understand that I must provide
sufficient information so the proper type of leave can be determined. I understand that I am responsible for keeping my
supervisor informed of any change in this request. If a medical condition is highly sensitive, immediately contact the Benefits
Manager at (303)-605-5321.
I request approval for total hours as listed below. Is the absence due to a work-related illness or injury?
No Yes
Record dates, times, and number of hours in the blanks before each applicable reason (More information may be required).
Actual Dates and Times
From To #Hrs.
Vacation (not related to care/treatment of a medical condition
or bonding with a new child).
Medical If not self, relationship
Routine eye, medical, dental exam.
Common illness/injury (no prescribed treatment e.g.,
cold, flu)
Other medical (inpatient or continuing treatment e.g.,
surgery, childbirth). Explain reason.
Other (explain reason and relationship, e.g., bonding, funeral,
jury, adoption, administrative leave).
Check Here if Form
Employee Signature Date Amended
To be Completed by Appointing Authority (or designee)
Annual FMLunpaid Unpaid Leave
Sick FMLholiday Administrative Leave
STD Jury Voluntary Furlough
FML annual Bereavement Comp. Time
FML – sick Military Other (specify)
A medical certification is required is not required. (Required for more than 3 full consecutive workings days).
A fitness-to-return certification will be will not be required before returning to work on a regular basis. (Required for an
absence of more than 30 days).
For purposes of family/medical leave designation, I have determined, as the appointing authority or designee, the following:
(Mandatory)
o the employee is not eligible for family/medical leave until (date).
o the employee is eligible but has already used the hours allowed in this fiscal year.
o the event does not qualify for family/medical leave.
o the employee is eligible for family/medical leave AND the event does, or could, qualify for family/medical leave. (The
State of Colorado Employer Individual Notice for Family and Medical Leave for must be completed and given to the
employee within 2 business days of this request, absent extenuating circumstances.)
o continuation of a previously designated event (continuing treatment or recovery).
Approved by Date
Immediate Supervisor or Designee Signature
Approved by Date
Appointing Authority, Designee, FML Coordinator Signature
Revised July 2020
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DEFINITIONS
Complete definitions of the various types of leave and the rules governing their use are found in Chapter 5 of the State
Personnel Director's Administrative Procedures. Additional information and assistance are also available in agency
human resources offices.
The appointing authority is responsible for approving the use and type of leave.
The employee is responsible for requesting leave as far in advance as possible and providing sufficient information
regarding the reason for the leave.
Please be accurate. State actual dates and times to be charged as leave. Incorrect information may cause errors and
delays in processing an employee's request for leave.
LEAVES
Annual Leave - paid leave typically used for personal/vacation purposes. Required to use concurrently when family/medical
leave applies.
Sick Leave - paid leave used for an employee's own medical examinations and treatment, physical inability to work due to
pregnancy, illness or injury. Required to use concurrently with family/medical leave. A
State of Colorado Medical
Certification
form is required for an absence of more than three consecutive regularly scheduled full working days or approval
of sick leave must be denied (per Colorado statute). It may be required for a lesser period.
STD (Short-Term Disability) Leave - After one year of service, granted while STD benefits are being paid and the employee
applies for the STD benefit within 30 days of the beginning of the absence or at least 30 days prior to the exhaustion of all
accrued sick leave. Must complete a waiting period or exhaust all accrued sick leave, whichever is longer. During the waiting
period, required to use sick leave and annual leave.
Unpaid Leave - The appointing authority may approve unpaid leave. This may result in an adjustment to the probationary or
trial service period and/or to the service date.
Administrative LeaveUp to 5 days for local or 15 days for national emergencies per fiscal year for employees who are
certified disaster service volunteers of the Red Cross; up to 90 days after military leave is exhausted for active military service
or up to 15 days in a fiscal year when qualified volunteers or members of the Civil Air Patrol are directed to report during a
declared emergency; 2 hours to participation in general elections; 2 days per fiscal year for organ transplant donations, or
other reasons the appointing authority deems for the good of the state.
Bereavement Leave - Up to 40 hours to make arrangements for, Travel to, attend funeral services or to grieve the loss of family
members or others. It does not cover settlement of an estate. Amount of time granted is based on relationship and distance
and travel mode of transportation required. Obituary notice maybe required.
Jury Leave - Used when an employee is called to serve jury duty. A copy of the summons for jury duty is required.
Family/Medical Leave (FML) - After one year of service, up to 520 hours in a fiscal year (prorated for part-time employees) may
be used for (1) birth and care of a child, (2) placement and care of an adopted or foster child, (3) a serious health condition of a
child, parent, spouse, or (4) the employee's own serious health condition. Use and type of concurrent paid leaves depends on
individual circumstances. For additional information, contact the FMLA Coordinator. A
State of Colorado Medical Certificate
form, as described above under sick leave, is often required
FML - annual: use of paid accrued annual leave when sick leave is exhausted or does not apply, including
caring for a new child.
FML - sick: use of paid accrued sick leave for an employee's serious health condition, including childbirth and
recovery or for a
serious health condition of an employee’s parent, spouse, or child.
FML - STD: use of STD leave for a serious health condition when an employee is eligible for STD benefits.
FML - LWOP: use of unpaid leave during family/medical leave when all other applicable paid leaves are
exhausted.
FML - holiday: when a holiday occurs during family/medical leave it counts toward the family/medical leave
entitlement.
ABSENCE
Compensatory Time - hours earned for approved overtime work by an eligible employee. Compensatory time is an absence
from the workplace but is not a form of leave.
Military Leave up to 15 work days in a fiscal year for permanent employees who are members of The National Guard,
Military Service, or National Disaster Medical Service. A copy of orders is required.