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APPLICATION FOR LEAVE
Employee Information:
Agency/Department:
Employee Name:
Number of Hours of Leave Requested:
From Date:
Time: AM PM
To Date:
Time: AM PM
Leave Information:
Chargeable Leave
Non-Chargeable Leave
Annual Leave Sick Leave LWOP
Military
Job Related
Education
Other (explain
in comments)
Civil:
Jury Duty
Witness Subpoena
Emergency Civilian
Voting
Special:
Funeral
Office Closure
Job Related Exam
If FMLA, select one of the following:
Self Military Caregiver
Family Qualifying Exigency
Comments:
If Part-Time, list number of hours worked each day.
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Employee Certification: I CERTIFY THAT MY ABSENCE FROM DUTY WAS FOR THE REASON NOTED ABOVE.
Employee Signature: Date:
Approval:
Supervisor Signature: Date:
Leave Definitions:
CHARGEABLE LEAVE: leave taken which reduces
accrued leave balances.
1. Annual: Leave with pay granted an
employee for the purpose of
rehabilitation, restoration and
maintenance of work efficiency, or
transaction of personal affairs.
2. Sick: Leave with pay granted an
employee who is suffering with a
disability which prevents him from
performing his usual duties and
responsibilities or who requires medical,
dental or optical consultation or
treatment.
3. LWOP: Leave without Pay
FMLA: (Family Medical Leave Act) approved
absence available to eligible employees for up to 12
weeks of leave per year for certain family medical
reasons.
Self: For employee’s own serious health condition.
Family: An immediate family member (spouse,
child, or parent) with a serious health condition.
Unpaid: When paid leave (annual/sick) is exhausted
or cannot be used under specific circumstances.
Military Caregiver: leave granted to care for a
family member who is a covered veteran with a
“serious injury or illness”.
Qualifying Exigency: may arise when a spouse, son,
daughter or parent who is a member of the Armed
Forces (including the National Guard and Reserves)
and who is on covered active duty or has been
notified of an impending call or order to covered
active duty.
NON-CHARGEABLE LEAVE: leave taken which does
not reduce accrued leave balances
1. Military: leave granted when called to
active military duty; annual training or
active duty for training (weekend drills);
to conduct mandatory physical to enlist in
military.
2. Job Related Education: leave granted to
attend a course that is relevant to job and
approved per provisions of PM 12.
3. Civil Leave: leave granted to:
a. perform jury duty
b. appear as subpoenaed before
a court, public body, or
commission
c. perform civil duties in
connection with national
defense or other civil
emergencies
d. vote
4. Funeral: Leave granted when
attending the funeral or burial rites of
a parent, step-parent, child, step-child,
brother, step-brother, sister, step-
sister, spouse, mother-in-law, father-
in-law, grandparent or grand-child;
provided such time off shall not exceed
two days on any occasion.
5. Office Closure: Chancellor determines
that because of local conditions it
would be impossible or impracticable
for the employee to report to work.
6. Job Related Exam: leave granted to
participate in a State Civil Service Exam
or to take other exams pertinent to the
employee’s position.
7. Other: Any other special or non-
chargeable leave request as provided
in Chapter 11 of the C.S. Rules
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