Name: ID #:
Please submit this completed form to your supervisor at least two weeks prior to your requested time off, if
possible. This improves the likelihood of approval.
Please avoid requesting to take time off during the week before and the first and last weeks of each semester.
For non-management employees: Compensatory time must be used within 12 months of earning so this option
should be used before using vacation time.
I would like to request time off as follows:
Beginning on (date): at (time):
Ending on (date): at (time):
Returning to work on (date): at (time):
This is a total of _________ to be allocated as follows:
Leave Type: (Please check at least one box below - do not leave blank.)
Compensatory Time Off (CTO)
Sick leave (sick/doctor/dentist)*
Personal Necessity (charged to sick leave)*
Well Day
Personal Holiday
Day off without pay (less than 12 month employees only)
Other (specify)
*These leaves may require confirming evidence.
Comments / explanations:
I confirm that I have accrued sufficient leave to cover this request, and that the request is consistent with my
conditions of employment. I also understand that time away from work is subject to approval, and that I may not be
absent without receiving prior approval.
Signature: Date:
Immediate Supervisor’s Signature: Date: