Request for Approval Of Leave Name (Print or Type): Employee’s This is to request approval of the following leave: Type of Approved From: Thru: Amount of Leave Leave (Initials) am am : Date Time Date Time Hrs Mins pm pm am am : Date Time Date Time Hrs Mins pm pm am am : Date Time Date Time Hrs Mins pm pm am am : Date Time Date Time Hrs Mins pm pm am am : Date Time Date Time Hrs Mins pm pm Leave Balance Before Requested Leave: Annual Sick Personal Leave Codes AL Annual Leave CL Court Leave* SL Sick Leave LWOP Leave Without Pay** ASSL Annual to Supplement Sick FLSA FLSA Compensatory Time PL Personal Leave SCT State Compensatory Time FUL Furlough FML/A Family Medical Leave/Annual BDL Blood Donation Leave FML/S Family Medical Leave/Sick ML Military Leave* FML/P Family Medical Leave/Personal * Copy of orders or subpoena must be attached Personnel Action Request form must be submitted ** REQUESTED BY: APPROVED BY: Signature Employee’s Signature Supervisor’s Date Date HR-03431A (Rev. 7/8/2013)
Request for Approval Of Leave Employee’s Name (Print or Type): This is to request approval of the following leave: From: Thru: Amount of Leave Type of Leave Approved (Initials) am pm am pm : Date Time Date Time Hrs Mins am pm am pm : Date Time Date Time Hrs Mins am pm am pm : Date Time Date Time Hrs Mins am pm am pm : Date Time Date Time Hrs Mins am pm am pm : Date Time Date Time Hrs Mins Leave Balance Before Requested Leave: Annual Sick Personal Leave Codes AL Annual Leave CL Court Leave* SL Sick Leave LWOP Leave Without Pay** ASSL Annual to Supplement Sick FLSA FLSA Compensatory Time PL Personal Leave SCT State Compensatory Time FUL Furlough FML/A Family Medical Leave/Annual BDL Blood Donation Leave FML/S Family Medical Leave/Sick ML Military Leave* FML/P Family Medical Leave/Personal * Copy of orders or subpoena must be attached ** Personnel Action Request form must be submitted REQUESTED BY: APPROVED BY: Employee’s Signature Supervisor’s Signature Date Date HR-03431A (Rev. 7/8/2013)
FMLAPacket_June2016.docx