HTML Preview Work Leave Application page number 1.
Oce of Human Resources, AFL001, rev. 3/14 Application for Leave, Page 1 of 2
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Application for Leave
SECTION 1: PERSONAL INFORMATION
Employee’s Full Name: First M.I. Last OSU Employee ID# (required)
Department College/Unit
SECTION 2: REASON(S) FOR REQUEST
LEAVE DESIGNATION: (Check all boxes that apply)
PAID LEAVE:
Dates
Family and Medical Leave*
Hours
Work Related Injury/Illness* Neither
Dates Hours
Vacation
Vacation in place of sick leave
Parental Leave
Organ Donation Leave
Compensatory Time
Jury Duty/Court Appearance*
Military Leave*
Sick Leave*
Please Specify:
Illness/Injury
Medical Appointment
Death in Family
Relationship*
Exposure to Contagious Disease
Self
Self
Family*
Family*
Total Hours Paid Leave:
UNPAID LEAVE: Medical* Personal*
Unpaid Time O* (10 or fewer consecutive working days) Beginning and ending dates
Unpaid Leave of Absence* (more than 10 consecutive working days) Beginning and ending dates
Last date worked Last date in active pay status
Extension of Previously Approved Leave of Absence*
Return date
Hours
Hours
Total Hours Unpaid Leave: University Business/Absence from Worksite (Dates):
ADDITIONAL INFORMATION: (Reason for absence, etc.)
I understand that approval of this request is contingent upon the availability of adequate leave balances. Falsification of this Application
for Leave or of the supporting documentation is grounds for disciplinary action, up to and including dismissal.
Employee Signature Date
SECTION 3: ADMINISTRATIVE ACTION
Date
Sta and faculty require the above signature. Faculty away for longer than 10 consecutive work days during an academic
semester, term or session require approval by the department, college and provost.
College/Unit Signature Date
Provost Signature Date
Approved Disapproved Comments:
SECTION 4: OPTIONAL
Person responsible in my absence: Phone
In an emergency, I may be reached through: Email Phone
*Any item followed by an (*) requires appropriate documentation. See reverse for explanation of documentation requirements.
Supervisor Signature