Leave Application Form Page 2

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IF YOU ARE A SHIFT WORKER, PLEASE INDICATE THE SHIFTS THAT WOULD HAVE BEEN WORKED IF NOT ON LEAVE.
Start
Start
Day
Date
End Time
Hrs
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Date
End Time
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Time
Time
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Mon
Tues
Tues
Wed
Wed
Thurs
Thurs
Fri
Fri
Sat
Sat
Sun
Sun
Start
Start
Day
Date
End Time
Hrs
Day
Date
End Time
Hrs
Time
Time
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Mon
Tues
Tues
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This leave application takes precedence over roster entries for this period, leave will be paid as per leave application. Therefore any changes or cancellation
to this application will require an amended form to be forwarded to HealthShare NSW.
Employee Signature
Date (DD-MMM-YY):
Leave entered into Roster System
Yes
No
Manager Signature
Does employee have sufficient
Yes
leave available:
No
Managers Contact
Phone Number
YES
NO
Would you like to receive an email notification
that this request has been actioned?
Email Address:
TO BE APPROVED BY HUMAN RESOURCES / EXECUTIVE***
***EXTENDED LEAVE WITHOUT PAY
Leave Types required to be submitted to HealthShare NSW:
Leave to be paid in Advance
Maternity leave
Adoption Leave
Paternal Leave
LSL
All internal procedures, including necessary approval and sign off, must be completed. If you are
unsure of your Local Health District (LHD) internal procedures, please contact your LHD.
Please note:
It is the responsibility of the LHD to ensure all internal LHD
procedures
have been followed
*** Please follow your internal Local Health District procedures to forward forms ***
HealthShare NSW Contact Details:
HSNSW-payroll@health.nsw.gov.au
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