TDCJ LEAVE REQUEST - Texas Department of Criminal Justice
TDCJ LEAVE REQUESTName (Print Last, First, Middle Initial) FORMTEXT ?????Payee ID Number FORMTEXT ?????TDCJ Unit/Department FORMTEXT ?????Position Title FORMTEXT ?????Salary Group and Rate FORMTEXT ?????Months of State Service FORMTEXT ?????Section I: Accrued Paid Leave Entitlements - All CategoriesCheck Type of Leave RequestedCurrent Leave BalancesFrom:(Date & Time)To:(Date & Time)Hours/Minutes FORMCHECKBOX Sick Leave FORMCHECKBOX Self FORMCHECKBOX Immediate Family FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Donated Sick Leave FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Overtime FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Compensatory Leave FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Holiday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Vacation FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Supervisor FORMCHECKBOX Approved FORMCHECKBOX DeniedSignature:Date:Alternate Date for Compensatory/Holiday Leave:Section II: Leave With Pay (Non-Accrued) - All CategoriesCheck Type of Leave RequestedFrom:(Date & Time)To:(Date & Time) FORMCHECKBOX Extended Sick Leave FORMTEXT ????? FORMTEXT ?????** Refer to PD-76 ** FORMCHECKBOX Authorized Training/Duty FORMCHECKBOX State Active Duty FORMCHECKBOX Federal Active Duty FORMTEXT ????? FORMTEXT ?????Administrative Leave FORMCHECKBOX Death in Immediate Family FORMCHECKBOX Adverse Weather (DM Required) FORMCHECKBOX Reserve Law Enforcement Training FORMCHECKBOX Jury Duty FORMCHECKBOX Veterans Health Administration Leave FORMCHECKBOX Service Dog Training FORMCHECKBOX State EMS/Firefighting/Search and Rescue Volunteer Training** Refer to PD-49 ** FORMCHECKBOX Urban Search and Rescue FORMCHECKBOX Other (Describe below) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Warden or Dept. Head FORMCHECKBOX Approved FORMCHECKBOX DeniedSignature:Date:Human Resources Director FORMCHECKBOX Approved FORMCHECKBOX DeniedSignature:Date:Administrative Leave Requiring Executive Director ApprovalExecutive Director FORMCHECKBOX Approved FORMCHECKBOX DeniedSignature:Date:Section III: Leave Without Pay (LWOP) - All CategoriesCheck Type of Leave RequestedFrom:(Date & Time)To:(Date & Time) FORMCHECKBOX LWOP/Military FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LWOP/Medical (FML, Sick Leave, Workers’ Comp) FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LWOP/Parental FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LWOP/Other FORMTEXT ????? FORMTEXT ?????Warden or Dept. Head FORMCHECKBOX Approved FORMCHECKBOX DeniedSignature:Date:Section IV: Employee Comments And SignatureEmployee Comments: FORMTEXT ?????Employee Signature:Date:Note to Employee: With few exceptions, you are entitled upon request: (1) to be informed about the information the TDCJ collects about you; and (2) under Texas Government Code §§?552.021 and 552.023, to receive and review the collected information. Under Texas Government Code §?559.004, you are also entitled to request, in accordance with TDCJ procedures, that incorrect information the TDCJ has collected about you be corrected. ................
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