Date of request: ______________ Employee name: _______________________
Department: _________________ Job title: _____________________________
PTO (Vacation/sick leave)
Start date: ________ End date: ________ Total hours: ________
Bereavement leave (Up to three days of paid leave due to a death in the immediate family is available.)
Start date: ________ End date: ________ Total hours: ________
Jury duty leave (Up to five days of paid leave for jury service is available.)
Start date: ________ End date: ________ Total hours: ________
Other
Policy name (e.g., sabbatical leave, school visitation, etc.): ____________________________
Start date: ________ End date: ________ Total hours: ________
This form should not be used to request leave under the Family and Medical Leave Act (FMLA) or to request leave as an accommodation under the Americans with Disabilities Act (ADA). Employees should consult with HR to request leave under the FMLA or ADA.
________________________________________ __________________
Employee signature Date
________________________________________ __________________
Supervisor signature Date
________________________________________ __________________
Human resources representative signature Date
File original in the employee's leave records and provide a copy to the employee and the employee's supervisor.
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