SJR State Leave Request Form

Employee Name: Employee ID: Date:

Please check section(s) needed and please use a separate form for each Month.

Vacation Leave

Balance: As of: Check Balance

Sick Leave

Illness - Employee Family Illness Medical Appointment - Employee Medical Appointment - Family Leave for Personal Death of Family Member

Balance: As of: Check Balance

Other Leave Types

Leave Without Pay Comp Time Jury Duty Wellness Day Professional Travel Other:

Begin: End: Total hrs:

FMLA

Absences below will be taken from appropriate leave balance and Family/Medical Leave allowance (This leave may only be used after written approval from Human Resources)

Using Vacation Leave Using Sick Leave Leave Without Pay

Begin: End: Total hrs:

Total Hours: 0

Signatures (after print)

Employee:

Date: ____________________

Supervisor:

Date: ____________________

VP/AVP/Dean/Director:

Date: ____________________

President:

Date: ____________________

Unchecked sections will be hidden in PDF to save space.
This form should be approved by the appropriate supervisor. Additional approval is needed from the Dean, Director, Provost, Vice President, or President and sent to the Office of Human Resources at least ten days prior to date of vacation leave. For all other leave, please submit as soon as possible. If leave status should change, notify the Office of Human Resources in writing immediately.
For questions concerning your leave call extension 4261.