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LEAVE REQUEST FORM
This form is to be completed by the employee and submitted to the employee's immediate supervisor for approval
and signature (s) at least one week prior to the date leave is requested to begin. Supervisor is expected to respond
within two (2) working days after receipt of request.
In the event leave is not approved, the form should be returned to the employee with an explanation for denial
stated in the "comments" section.
Employee Name Print: __________________________________ Date of Hire: __________________
Department/Division: ___________________________________ Date of Request: ________________
Type Leave:
( ) Vacation ( ) Personal ( ) Jury Duty Sick Bereavement
( ) FMLA ( ) Other ____________________________
Begin Date: _____________ End Date: _______________ Total Requested: __________________
If less than one day: Begin Time: ___________ End time: ___________ Date: ______________
Employee Signature: ____________________________________
The leave requested on this form also applies to a new or current Yes No
Family & Medical Leave Act (FMLA) covered event.
LEAVE APPROVED: ___ LEAVE DENIED: ___
Comments: __________________________________________________________________________
____________________________________________________________________________________
Employee Signature : ________________________________________ Date: __________________
Immediate Supervisor's Approval : _______________________________ Date: __________________
Sr. PM's Approval : ___________________________________________ Date: __________________
VP/ Asso Provost Signature : _____________________________________ Date: ___________________
Please submit completed form to VP/HR Admin.
