LEAVE REQUEST FORM Furlough
LEAVE REQUEST FORM
|Employee Name: | |Employee ID: | |
|Position: | |Department/Division: | |
|Number of Hours: | |From Date/Time: | |To Date/Time: | |
|Leave Requested/Used: |
| |Vacation Request |
| |Sick Leave |
| |Non-FMLA Medical Leave |
| |Bereavement |
| |Civic Duty: |
| |Specify:__________________________ |
| |Furlough |
| |Other: |
| |Specify: _________________________ |
|How Leave is to be Paid: |
| |Paid Leave |
| | |Vacation |
| | |Sick Leave |
| | |Comp Time (Hourly employees only) |
| | |Other: |
| | |Specify: |
| |Unpaid Leave |
| | |Short Term Disability |
| | |Long Term Disability |
| | |Furlough (No Pay) |
|This form is NOT INTENDED to be used for any leave that qualifies for or that is designated as Family or Medical Leave under the Family & Medical Leave Act (See |
|Policy 405) |
Authorization Signatures:
| | | |
|EMPLOYEE SIGNATURE & DATE | |SUPERVISOR SIGNATURE & DATE |
Comments:
| |
\Effective 7/20/01, revised 3/17/2010
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