Provide the name of the employee requesting leave or travel authorization and the date of the request.
Indicate the dates of occurrence.
Indicate the employee's department name and other contact information.
Indicate type of leave. Professional - attending conference, etc.; Education - continuing education; Vacation - compensated annual leave; Family Medical Leave Act; Sick Leave - planned use of sick leave for extended period of time; Other - military, jury duty, non-paid leave, bereavement.
If this leave/travel request is for University business, indicate the purpose of the travel. List which account(s) will be charged for travel expenses if this is for University business and record the estimated cost of the travel.
International travel requires the Dean's approval. Domestic travel includes travel to Canada and to U.S. possessions and territories. Indicate the origination site of the travel; for example, New Orleans, Alexandria, Biloxi. Indicate the city of travel destination.
List who is responsible for covering services during the absence of the employee.
List an emergency number where the employee can be reached or where a message can be retrieved by the employee.
Provide the signature of the employee requesting leave or travel authorization. Other signature lines are for approvals as required by University procedures. All University travel must be approved by an employee's supervisor and/or chairperson. Chairpersons, Center Directors and Associate Deans must have their leave and travel approved by the Dean. All international travel must be approved by the Dean in advance of travel.
A. Completion of this form does not exempt one from having to follow established personnel policies for requesting "Family Medical Leave" or "Leave of Absence".
B. Approved leave request forms are to be filed in the respective employee's department records.