(To be completed by Employee)
| | (To be completed by Employee) |
|Sec|Employee Name: | |
|tio| | |
|n A| | |
| |Employee Identification No.: |T |Department: | |
| |I request my absence be charged to (Check appropriate box): |
| | | |Sick | |Vacation | |Jury Duty |
| | | |Compensatory Time | |Military - paid up to 15 calendar days per year |
| | | |Other | |Leave of Absence (L) - up to 10 days |
| |NOTE: For illness of more than three (3) working days, a statement from the attending physician must be attached. |
| |Date(s) of Absence: |From: | |To: | |No. of Days: | |
| |Time/hours of Absence: |From: | |To: | |No. of Hours: | |
| |Reason for Absence: |
| | |
| | | | |
| |Employee Signature | |Date |
| | (To be completed by Supervisor) |
|Sec| | |Approved |
|tio| | | |
|n B| | | |
| | | |Disapproved |
| |Comments: |
| | |
| | | | |
| |Manager Signature | |Date |
| | (To be completed by Administrative Officer/Dept. Head) |
|Sec| | |Approved |
|tio| | | |
|n C| | | |
| | | |Disapproved |
| |Comments: |
| | |
| | | | |
| |Administrative Officer/Dept. Head Signature | |Date |
-----------------------
IN-HOUSE FORM
(Keep In Department)
................
................
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