Leave Of Absence Request Form - Cal State La California State
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California State University, Los Angeles
University Auxiliary Services Inc.
LEAVE OF ABSENCE REQUEST FORM
An employee requesting time off with or without pay for more than 15 working days, must submit an approved and complete Leave of
Absence Request Form to UAS HR at least two working days prior to the start of the leave. If the leave request exceeds 90 calendar days,
UAS Executive Director must also approve. If additional time off is required after the 90 days, a new form must be submitted. Failure to
submit a new form may be cause for termination of employment.
Please check appropriate box:
CORPORATE
AGENCY
CONTRACTS & GRANTS
Last Name, First Name, Middle Initial
Hire Date
Last four digits of SS#
Home Address (City, State, Zip)
Home phone (area code & number)
Name/phone ext. of direct supervisor
Job Title
Department
Date of Absence:
Beginning Date______________________________ End Date_________________________________________
Reason for Absence: (In detail)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Project Name
Account
Fund
Organization
Program
Project
Classification
Pay/Unit
ID
Code
Rate
2002
Employee Signature
Date
Supervisor Name
Signature
Date
- I hereby certifiy that this employee’s Leave of Absence is
in compliance with the project’s regulations and his/her absence will
not affect the progress of the project. (for C&G only)
UAS HR Director Recommendations
Signature
Date
PTO Accrual
Benefit continuation
Hold position
UAS Executive Director
Signature
(over 90 days)
Approved
yes
no
Copies to: UAS HR, Payroll, Contract and Grants
UAS3012 rev. 5/06
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Parent category: Business