PA-4: Exempt Staff Time Off Reporting Form
Please print or type all information. Exempt Staff only.
Rev. 6/2009
1. Employee’s Name
_______________________________________________________________________________
(Last, First, Middle)
2. Social Security Number _______________________________________ 3. Ext. ________________
4. Time-Off Start Date: /20________ Time-Off End Date /20________
5. Reason for Time-Off (Please report as hours off):
Vacation Total Hours Off: (number of days x 7.5) =____________________
Sick Leave Total Hours Off: (number of days x 7.5) =____________________
Floating Holiday Total Hours Off: (number of days x 7.5) =____________________
Jury Duty/Court Appearance Total Hours Off: (number of days x 7.5) =____________________
Bereavement Leave Total Hours Off: (number of days x 7.5) =____________________
Other (Explain): __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
6. Memo: ____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
SIGNATURES
Employee ______________________________________________________ Date _____________________
Supervisor _____________________________________________________ Date _____________________
Payroll ________________________________________________________ Date _____________________
