Z1(a) - Application for leave of absence
Instructions:
Complete the form using Adobe Acrobat Reader and print.
Date format:
d mmmm yyyy = 1 January 2013
for example
typing “1 01 2013” will result in “1 January 2013”
Time format:
HH:MM = 13:30
typing “13:30” will result in “13:30”
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Z1 (a)
APPLICATION FOR LEAVE OF ABSENCE
Surname
Initials:
PERSAL Number:
Shift Worker
Yes
No
Address during the Leave Period:
Tel. No.:
Casual Employee
Yes
No
Department
Component
SECTION A: For Periods covering full day
Type of Leave Taken as Working Days
Start Date
End Date
Number of Working Days
Annual Leave
Normal Sick Leave
1
Temporary Incapacity Leave
This application form must not be used to apply for temporary incapacity leave. Temporary incapacity
leave must be applied for on the application form prescribed in terms of the Management Policy and
Procedure on Incapacity Leave and Ill-health Retirement for Public Service Employees. Please contact
your Personnel Office for further information.
Leave for Occupational Injuries and Diseases
Adoption Leave
2
Family Responsibility Leave (Provide Evidence)
Pre-natal Leave (Provide Evidence)
Paternity Leave (Provide Evidence)
Special Leave
Specify Type of Special Leave
Leave for Union Office Bearers (Provide Evidence)
Leave for Union Shop Stewards (Provide Evidence)
Specify Union Affiliation
Type of Leave Taken as Calendar Days/Months
Start Date
End Date
Number of Calendar Days
Unpaid Leave (Provide motivation)
Maternity Leave (Attach medical certificate)
No. of Calendar Months
SECTION B: For periods covering parts of a day or fractions
Type of Leave Taken as Working Days
Date
Start Time
End Time
Number of Hours/ Minutes
Annual Leave
h
m
Normal Sick Leave
h
m
Family Responsibility Leave (Provide Evidence)
h
m
Pre-natal Leave (Provide Evidence)
h
m
Paternity Leave (Provide Evidence)
h
m
Special Leave
h
m
Specify Type of Special Leave
Leave for Union Office Bearers (Provide Evidence)
h
m
Leave for Union Shop Stewards (Provide Evidence)
h
m
Specify Union Affiliation
I hereby certify that I have acquainted myself of my available leave credits and with the rules governing the leave I have applied for. Further, I am certifying that the information provided is correct. Any
falsification of information in this regard may form ground for disciplinary action. Furthermore, I fully understand that if I do not have sufficient leave credits from my previous or current leave cycle to cover for
my application, my capped leave as at 30 June 2000 will be automatically utilised.
________________________________________ _________________________
EMPLOYEE SIGNATURE DATE
Recommendation by Supervisor/Manager (Mark with X)
Recommended
Not Recommended
Rescheduled
REMARKS (If not recommended please state the reasons & the dates in the case of rescheduling):
________________________________________________________________________________________________________________________________________
_______________________________________ _____________________
MANAGER’S/SUPERVISOR’S SIGNATURE DATE
Approval by Head of Department (Mark with X)
Approved With Full Pay
Approved Without Pay
Not Approved
REMARKS (If approved with a change in condition of payment or not approved, please provide motivation):
________________________________________________________________________________________________________________________________________
_____________________________________ ___________________
SIGNATURE OF HOD OR DESIGNEE DATE
Data Capturing
Captured By:________________________________ Captured On _______________ Signature___________________
Checked By:_________________________________ Checked On:_________________ Signature___________________
1
Applications in respect of sick leave of three or more days must be accompanied by a medical certificate issued by a registered medical practitioner.
2
Applications for adoption leaves must be accompanied by a declaration on how the entitlement will be used in the case where both spouses are in the employ of the Public Service.
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