Revised September 2020
REQUEST FOR LEAVE/REPORT OF ABSENCE
NAME:
COLLEAGUE ID: (REQUIRED)
DEPT:
DATE:
TYPE OF LEAVE DATE (S)
TOTAL NUMBER
OF HOURS
Sick Leave
Vacation
Personal Business
Floating Holiday
Bereavement Leave (Refer to Bd
Policy #4009)
Relationship:
Jury Duty (Attach copy of Summons)
Leave of Absence Without Pay
(Refer to Bd Policy #4032, 4033,
4033.1)
FMLA Leave
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 fiscal year, I will owe the college for any time used, but not
earned.
Employee Signature: _________________________________________ Date: ____________________
Supervisor Approval: __________________________________________ Date: ___________________
After approved signature, make a copy for your supervisor and attach the original to employees timesheet.