University of Central Missouri
Request for the Crisis Leave Program
F:\HRFORMS\2003 Crisis Leave Request Form.doc
I understand that as a regular employee I must have exhausted all of my available vacation leave, sick
leave, and all other leave (compensatory, personal, etc.) in order to apply for crisis leave. I also must
have been employed at Central for at least one year and either a) experienced a catastrophic illness or
injury, or b) must provide care for a member of my immediate family who has experienced a catastrophic
illness or injury.
Name (please print): ________________________________ Employee Number: __________________
Department: ___________________________________ Job Title: ____________________________
Campus Address: ______________________________ _ Campus Phone: _______________________
Number of Days being requested (1day=8 hours) ________________ (Please check all that apply to this
My request is a serious health condition for myself as defined by FMLA*.
My request is for a serious health condition of the immediate family member as defined by FMLA*.
*FMLA paperwork must be submitted separately to The Office of Human Resources, ADM 101.
Date absence is to begin: ____________________ Date absence is to end: _____________________
Employee Signature: _________________________________________ Date: ___________________
Supervisor Acknowledgement:
Supervisor’s Name (please print): ________________________________________________________
Campus Address: ______________________________ _ Campus Phone: _______________________
Supervisor’s Signature __________________________________________ Date: _________________
Please return this form to the Office of Human Resources, ADM 101.
NOTE: The Office of Human Resources will retain this form and contact the employee and employee’s
department as to the status of this request. The supervisor is responsible for making sure an absence
form is submitted by the employee documenting the use of crisis leave.
Office of Human Resources only:
Days Requested: ______ Days Approved: ______ Leave Dates: ____________________
Leave Denied: ______ Reason: ________________________________________________________
Annual Salary: $_____________ Hourly Amount: $____________
FMLA paperwork on file with HR: _____Yes _____No
Approval Signature: ____________________________________ Date: ____________________
Leave deducted from Crisis Leave Accruals____________ (# of hours) Remaining hours: ____________
Processed by: ________________________________________ Date: ____________________