Application For Leave Of Absence
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1Clear Form
STATE OF HAWAII
APPLICATION FOR LEAVE OF ABSENCE
DATE
I,
, apply for a leave of absence as follows:
(
)
PRINT YOUR NAME CLEARLY
working
of
a. WITH PAY, charged to
(
)
TYPE OF LEAVE
for the calendar period from
to
:
(
)
(
)
(
)
(
)
(
)
(
)
DAY
MONTH
YEAR
DAY
MONTH
YEAR
b. WITHOUT PAY, for the purpose of
*
(
)
TYPE OF LEAVE
for the calendar period from
to
:
(
)
(
)
(
)
(
)
(
)
(
)
DAY
MONTH
YEAR
DAY
MONTH
YEAR
A doctor’s certificate
attached.
(
)
(
)
IS
IS NOT
(
)
SIGNATURE OF EMPLOYEE
Date:
. Approval
recommended.
(
)
(
)
(
)
IS
IS NOT
SIGNATURE OF SUPERVISOR
Date:
. Approval
granted.
(
)
(
)
(
.
)
IS
IS NOT
SIGNATURE OF DEPT
HEAD
THE USE OF THIS SECTION IS NOT MANDATORY.
DEPARTMENTS MAY UTILIZE ONLY SUCH ITEMS CONSIDERED NECESSARY BY THEM.
LEAVE STATUS OF EMPLOYEE
VACATION
SICK LEAVE
1. Credits accumulated as of Jan. 1, this year……………………………………
2. PLUS credit earned from Jan. 1 to date…………………………………….…
3. Total credits to date……………………………………………………………
4. LESS leave taken from Jan. 1 to date………………………………………….
5. NET or unused leave credits as of this date…………………………………..
6. Number of days leave taken LAST YEAR……………………………………
INSTRUCTIONS
1. This form is to be retained by each department for its use. Only when a specific need arises, such as an appeal
hearing, will the Dept. of Personnel Services request that these forms be submitted.
2. Each department will specify the number of copies to be prepared by its employees.
3. One copy of this form will be given to the employee who has taken a leave.
4. FOR ALL LEAVES WITHOUT PAY AND SUSPENSIONS – Such cases will be reported through State DPS
Form 5, to the Dept. of Personnel Services and the State Comptroller
* Types of leaves – Such as vacation, sick, maternity, health, military, education, sabbatical, etc.
-1 (
5/1/76)
FORM G
REVISED
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