Delaware Technical & Community College
LEAVE REQUEST FORM(Please type or print using ink)
___________________________________Last Name First Name M.I.
___________________________________Employee ID #
Month _______________________________________________ 20______________(Only one month per form)
Note: 1 Day = 7.5 hours Calculate to the nearest quarter hour TYPE OF LEAVE 00/font> AnnualDate _____________ Hours ____________
Date _____________ Hours ____________
Date _____________ Hours ____________
Date _____________ Hours ____________
Date _____________ Hours ____________ Total Hours ____________ 00/font> SickCheck One
Date ____ Hours _____ 00Self 00/b> Family 00/b> Personal*
Date ____ Hours _____ 00Self 00/b> Family 00/b> Personal*
Date ____ Hours _____ 00Self 00/b> Family 00/b> Personal*
Date ____ Hours _____ 00/b> Self 00/b> Family 00/font> Personal* Date ____ Hours _____ 00Self 00/b> Family 00/font> Personal*Total Hours _____ *Total Personal Hours _____
00/font> OtherDate _____________ Hours ____________
Date _____________ Hours ____________
Date _____________ Hours ____________Date _____________ Hours ____________
Date _____________ Hours ____________Total Hours ____________
Circle one below (not to be charged against annual or sick leave):
Unpaid Absence, Family Medical Leave Act (unpaid, up to 12 weeks),
Bereavement (relationship of deceased to employee _________________________________),
Jury Duty (attach documentation),
Military Leave (attach documentation)
00/font> Compensatory Time Date _____________ Hours ____________Date _____________ Hours ____________
Date _____________ Hours ____________Date _____________ Hours ____________
Date _____________ Hours ____________Total Hours ____________
Employee Type:00/font> Regular 00Temporary
IMMEDIATE SUPERVISOR APPROVAL:Immediate Supervisor is responsible for verification of ALL leave. Employee MUST HAVE leave available in order to use it.
__________________________ __________
Date
DEAN/DIRECTOR OR APPROPRIATE ADMINISTRATOR APPROVAL:
___________________________ _________
Date
EMPLOYEE SIGNATURE:_______________________ ___________
Date
*Personal Leave 00only 3 sick days per calendar year are permitted to be used as personal leave & must be taken in no less than full day increments (7.5 hours). See Section 7.02(a), 3. Sick Leave, in the Personnel Policy Manual for further information.
Distribution:
00/font>
H.R. Office
00/font>
Employee
00/font>
Dean/Director/Appropriate Administrator Revised 4-3-07
