Overload Hours Period(s) Day(s) Date(s)
SUBMIT ORIGINAL TO: Human Resources RETAIN COPIES FOR: Requestor and Supervisor
Name____________________________________________________ Department ___________________________________________
□AM
First Day Absent _____________ 20_____ Hour Starting __________ □PM Campus _________________ Ext. ____________
Check one: □S □M □T □W □R □F □S B # ______________________________________
Regular Hours ____________________________
Last Day Absent _____________ 20_____ Hour Ending __________ a.m. /p.m. (FacultyOnly) Overload Hrs _________________
Check one: □S □M □T □W □R □F □S Total Hours Absent _________________________
Type of Leave (See Operational Procedures Manual)
Leave of Absence with Pay ✔ Leave of Absence Without Pay ✔
□ Vacation □ Line of Duty* □ Professional
□ Sick □ Professional* □ Maternity
□ Personal □ Jury Duty (Jury Summons and □ Personal
□ Worker’s Compensation Jury Attendance Certification
□ Military* must be attached)
Remarks *Destination (if applicable) and reason for leave; multiple occupancy for travel, etc.
OUT-OF-STATE TRAVEL REQUIRES APPROVAL OF THE DISTRICT PRESIDENT
REQUEST FOR LEAVE OF ABSENCE
NO FUNDING REQUESTED
Regular Hours Period(s) Day(s) Date(s) Name of Substitute
______________________________________ _________________________________________
REQUESTOR DATE PROVOST DATE
___________________________________________________ _______________________________________________________
SUPERVISOR DATE VICE PRESIDENT/ASSOCIATE VICE PRESIDENT DATE
___________________________________________________ _______________________________________________________
DEPARTMENT CHAIR/DIRECTOR OR DEAN DATE PRESIDENT DATE
EQUAL OPPORTUNITY EMPLOYER
HR-051 Rev. 11/10
For Faculty (List classes and/or other activities requiring paid substitutes)
