Leave Request Form
ADVERTISEMENT
1REQUEST FOR LEAVE
NAME__________________________College of Charleston ID# (CWID#)________________
DEPARTMENT_____________________________________
Permission is requested to take leave on the date(s) listed below.
Date
Beginning at
Ending on
Total Hours
Leave Code
Remarks
(hour/minute)
(hour/minute)
Requested
No.
Leave Code No.
Leave Code No.
1. Annual Leave
7. Voting Leave
2. Personal Sick Leave/Medical Appt.*
8. Military Leave***
__three or less days __over three days
__15 days or less __over 15 days
3. Family Sick Leave/Medical Appt.*
9. Death in Family
__three or less days __over three days
Relation: _________________
4. Birth of Child*
10. Court Leave***
5. Adoption/Foster Care**
11. Compensatory Leave
6. Leave Without Pay
12. Other ____________________
Does This Leave Qualify Under the Family and Medical Leave Act (FMLA) Yes __ No__
Employee Signature _______________________________Date____________
Departmental Approval _____________________________Date____________
Please use this form for all leave requests.
*May require medical certification; send copy of leave request form to Human Resources.
**May require legal papers; send copy of leave request form to Human Resources.
***Court Summons/military orders required; send copy of summons/orders to Human
Resources.
Send copy of request form to Human Resources when leave qualifies under FMLA.
Sick Family Leave – up to 10 days/calendar year
Immediate family includes spouse, children, mother, father, sister, brother, grandparents, legal
guardian and grandchildren (when the grandchild resides with the employee and the employee is
the primary caretaker of the grandchild) of either the employee or the spouse.
Death in the Immediate Family – up to three consecutive workdays with pay for death of spouse,
parents, grandparents, great-grandparents, brothers, sisters, children, grandchildren and great-
grandchildren of either the employee or the spouse.
revised 11/11 – HR 01200
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business