Monthly Leave Report
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MONTHLY LEAVE REPORT
Name
Month and Year
Day of Month
Annual
Sick
Misc.
Day of Month
Annual
Sick
Misc.
Leave
Leave
Leave
Leave
Leave
Leave
Beginning Balances
19
1
20
2
21
3
22
4
23
5
24
6
25
7
26
8
27
9
28
10
29
11
30
12
31
13
14
15
Hours Used
0
0
0
16
Subtotal
0
0
17
Hours Earned
18
Ending Balances
0
0
0
The leave requested on this form also applies to a new or current Family Medical Leave Act (FMLA) covered event.
Yes
No
This report must be completed, signed and returned to the department representative on your last working day of each month.
Signed ______________________________________________________________________________________
Signature of person requesting leave
Date
I understand the time during which I am using paid leave will run concurrently with any Family & Medical and Leave Act (FMLA) leave to which I am entitled, and I may
read more about my FMLA rights at
Approved by __________________________________________________________________________________
Signature and title
Date
I understand that under certain circumstances, the Family and Medical Leave Act (FMLA) provides job protection during periods of paid or unpaid leave. If applicable, I
will take the appropriate steps to initiate the FMLA job protection process as per information at
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