Crisis Leave Request Form printable pdf download

Crisis Leave Request Form

Employee Name: ___________________________________________________

Personnel Number: __________________________

Department: ______________________________________________________

I am requesting ____________ days of leave from the Crisis Leave Pool to begin on

___________. I understand that I must exhaust all of my accrued but unused vacation

leave, sick leave and compensatory leave* (as may be applicable to the purpose of my

crisis leave request) before receiving this leave from the Crisis Leave Pool. I also

understand that Crisis Leave received will not exceed the number of vacation days I

accrue in one year. I am requesting leave for the following reason(s).

My own serious health condition.

The serious health condition of my spouse, child, parent or a person

bearing the same relationship to my spouse.

An extraordinary non-health related personal crisis

Please provide a brief summary of your reason for this request:

_______________________________________________________________________

Employee Signature: ___________________________________ Date: _________

Department Head: _____________________________________ Date: _________

Dean or Director: ______________________________________ Date: _________

Payroll: ______________________________________________ Date: _________

Asst. Vice Chancellor HR: ________________________________ Date: _________

*Including the use of vacation and sick leave to a negative 40 hour balance.

Crisis Leave Request Form