REQUEST FOR LEAVE/REPORT OF ABSENCE
Name __________________________________________________________ Date __________________________________________
Department _____________________________________________________________________________________________________
Type of Leave Date (s) and Total # of Hours
Sick Leave ________________________________________________________________________
Vacaon ________________________________________________________________________
Personal Business ________________________________________________________________________
Floang Holiday ________________________________________________________________________
Bereavement (Refer to Board Policy #4009) ________________________________________________________________________
(Relaonship _______________________)
Jury Duty (Aach copy of summons) ________________________________________________________________________
Leave of Absence Without Pay ________________________________________________________________________
(Refer to Board Policy #4032, 4033, 4033.1)
Comp Time Leave ________________________________________________________________________
Other ________________________________________________________________________
By signing this form I verify that I will be taking or have taken the above leave. I understand that if I leave
employment before the end of the scal year, I will owe the college for any me used but not earned.
Employee Signature _______________________________________________ Date ____________________________________________
Supervisor Approval _______________________________________________ Date ____________________________________________
Aer approved signature, make a copy for your supervisor and aach the original to employee’s mesheet.
Revised August 2017
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