Request For Leave Or Approved Absence/compensatory (Comp) Time Form - University Of North Alabama
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1UNIVERSITY of NORTH ALABAMA
Police Department
/COMPENSATORY (COMP) TIME
REQUEST FOR LEAVE OR APPROVED ABSENCE
1. NAME (Last, First, Middle Initial)
2. EMPLOYEE OR SOCIAL SECURITY NUMBER
3. REQUEST FOR COMPENSATORY
DATE
TIME
TOTAL
5. PURPOSE
From:
To:
From:
To:
HOURS
(COMP) TIME
(Check appropriate box below)
9
Compensatory Time Earned
4. TYPE OF LEAVE/ABSENCE
DATE
TIME
TOTAL
5. FAMILY AND MEDICAL
(Check appropriate box(es) below)
From:
To:
From:
To:
HOURS
LEAVE
9
Accrued Annual Leave
If annual leave, sick leave, or leave
without pay will be used under the
9
Family and Medical Leave Act of 1993,
Advance Annual Leave
please provide the following information:
9
9
I hereby invoke my entitlement to
Accrued Sick Leave
Family and Medical Leave for:
9
9
Birth/Adoption/Foster Care
Advance Sick Leave
9
Serious Health Conditions of
9
9
Purpose:
Spouse, Son, Daughter, or
Medical/dental/optical examination of requesting employee
Other
Parent
9
9
Care of family member/bereavement, including medical/dental/optical
Serious Health Condition of Self
examination of family member
9
Contact your supervisor and/or your
Compensatory Time Off
personnel office to obtain additional
information about your entitlements and
9
responsibilities under the Family and
Other Paid Absence
Medical Leave Act of 1993.
9
Leave Without Pay
6. REMARKS
7. CERTIFICATION: I hereby request leave/approved absence from duty as indicated above and certify that such leave/absence is requested for the purpose(s)
indicated. I understand that I must comply with my employing agency’s procedures for requesting leave/approved absence (and provide additional documentation,
including medical certification, if required) and that falsification of information on this form may be grounds for disciplinary action, including removal.
EMPLOYEE SIGNATURE
DATE
9
9
8. SUPERVISOR ACTION:
APPROVED
DISAPPROVED (If disapproved, give reason. If annual leave, initiate action to reschedule.)
SIGNATURE
DATE
PRIVACY ACT STATEMENT
The primary use of this information is by management and your payroll office to approve and record your use of leave. Additional disclosures of the information my be: To the
Department of Labor when processing a claim for compensation regarding a job connected injury or illness; to a State unemployment compensation office regarding a claim; to Life
Insurance or Health Benefits carriers regarding a calim; to a Federal, State, or local law enforcement agency when your agency becomes aware of a violation or possible violation of
civil or criminal law; to a Federal agency when conducting an investigation for employment or security reasons;
Where the employee identification number is your Social Security Number, collection of this information is authorized by Executive Order 9397. Furnishing the information on this
form, including your Social Security Number, is voluntary, but failure to do so may result in disapproval of this request.
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