Form Tl-610 - Leave Of Absence Form

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LEAVE OF ABSENCE FORM
Employee Name _________________________________________
EMPL ID _______________________________
Last Name First (print or type)
Department Name _______________________________________
Department Number ____________________
Reporting Period: ___________ through ____________ (reporting periods posted on web site )
This is a two-purpose form. Mark (x) for the purpose that you need at this time:
( ) Initial REQUEST ( ) CORRECTION (time planned or taken varies from initial request)
INSTRUCTIONS FOR COMPLETION, ANY NECESSARY ATTACHMENTS,
AND DISTRIBUTION ARE ON THE BACK OF THIS FORM
Hours of
Time Period Of Leave
Leave
From
To
Leave Type/Time Reporting Code
Date
Time
Date
Time
1 hr. 15 min. =
(mm/dd/yy)
(mm/dd/yy)
1.25
AM
AM
FT=CRU
PT=CRH
PM
PM
Court Related
AM
AM
Contact HR
PM
PM
Family Medical Leave Act (FMLA)
FT=WCU
PT=WCH
AM
AM
Contact Risk Mgmt
PM
PM
Illness/Injury In Line-Of-Duty
AM
AM
FT=MIL PT=MIH
PM
PM
Military
AM
AM
PLU
PM
PM
Personal Leave
AM
AM
LWP
PM
PM
Personal Leave Without Pay
AM
AM
LWP
PM
PM
Professional Leave Without Pay
AM
AM
Contact HR
PM
PM
Sabbatical
AM
AM
SLU
PM
PM
Sick Used: Illness of: ____________
AM
AM
SLU
PM
PM
Sick Used: Illness of: ____________
AM
AM
SLU
PM
PM
Sick Used: Illness of: ____________
AM
AM
SLC
PM
PM
Sick Leave Carryover Used
SPU
AM
AM
Contact HR
PM
PM
Sick Leave Pool Used
AM
AM
ALU
PM
PM
Annual Leave Used
AM
AM
ALU
PM
PM
Annual Leave Used
AM
AM
ALU
PM
PM
Annual Leave Used
AM
AM
EMG
PM
PM
Emergency College Closing
AM
AM
CMU
PM
PM
Compensatory Time
AM
AM
CMU
PM
PM
Compensatory Time
Signatures:
Employee _________________________________________________
Date _______________________
Approvals:
Immediate Supervisor _______________________________________
Date _______________________
The following approval only necessary for leave which extends for more than 37.5 hours or for leave without pay:
Next level Supervisor _________________________________________
Date _______________________
HR Action\Forms\TL-610 Leave of Absence Form.xls
TL-610
Rev 07/14/2010

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