Employee Leave Request - County Of Washington, Virginia

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COUNTY OF WASHINGTON, VIRGINIA

EMPLOYEE LEAVE REQUEST

DEPARTMENT OF BUDGET & FINANCE

EMPLOYEE INFORMATION

EMPLOYEE NAME:

EMPLOYEE NO.:

HIRE DATE.:

Last

First

MM/YY

FULL-TIME

PART-TIME

EMPLOYEE STATUS:

EXEMPT

NON-EXEMPT

FLSA STATUS:

LEAVE REQUEST

I THE UNDERSIGNED EMPLOYEE DO HEREBY REQUEST USE OF THE FOLLOWING LEAVE:

LEAVE

TOTAL

LEAVE

DATE

DATE OF

HOURS

LEAVE

HOURS

LEAVE

RETURN TO

FORM OF LEAVE

REASON FOR LEAVE

BEGINNING

HOURS

BALANCE

BEGINS

WORK

BALANCE

REQUESTED

REMAINING

(MM/DD/YY)

†

PAID TIME OFF

(PTO)

SICK LEAVE (SL)

COMPENSATORY

TIME (CT)

JURY LEAVE*

FAMILY MEDICAL

LEAVE ACT (FMLA)*

†

Balance should reflect any previous approved Leave hours taken during this month

* Must be approved by County Administrator or his/her Designee for all employees

EMPLOYEE SIGNATURE

DATE SUBMITTED:

Signature of Employee

DESPOSITION OF REQUEST

APPROVED

DENIED

THIS ABOVE REQUEST IS:

REASON FOR DENIAL:

DATE:

Initials - Dept Director/Co Admin or his/her Designee

GENERAL INFORMATION

P.T.O. Leave and Compensatory Time

P.T.O. Leave and Compensatory Time (Comp Time) requests of no more than 2 successive working days must be submitted to the employee's Department Director/County

Administrator or his/her Designee at least 24 hours in advance of the date the leave is requested. Generally, use of Compensatory Time limited to no more than 3 successive

working days in any 14 calendar day period will be approved unless the employee's absence will unduly disrupt County operations.

P.T.O. Leave requests in excess of 2 successive working days but less than 5 successive working days must be submitted at least 3 working days in advance of the date the leave

is requested. P.T.O. Leave requests of 5 successive working days or more must be submitted at least 5 successive working days in advance of the date the leave is requested.

Sick Leave

Where the use of Sick Leave is known in advance, employees shall generally follow the policies for use of P.T.O. Leave above. When use of leave cannot be approved in advance,

this Request for Use of Leave form shall be submitted for approval within 2 working days of an employee's return to work.

Jury Leave and fmla Leave

Requests for Jury Leave and FMLA Leave must be submitted to the County Administrator or his/her Designee. Where use of such leave is known in advance, employees shall

generally follow the policies for use of P.T.O. Leave above. When use of leave cannot be approved in advance, this form shall be submitted to the County Administrator or his/her

Designee within 2 working days of an employee's return to work. Employees are urged to review the relevant sections of the County Human Resources Policy Manual prior to

submitting requests for Jury Leave and FMLA Leave

06-06