"Employee Leave Request Form - Central Point School District 6"

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EMPLOYEE LEAVE REQUEST FORM
NAME:
___________________________________________________________________________________________
DATE(S) OF
LEAVE: ________________________________________________________________________________
REASON FOR LEAVE*: ______________________________________________________________________________
* NOTE: ANY EMPLOYEE WHO FALSELY CERTIFIES IN THIS RESPECT SHALL BE LIABLE FOR DISCIPLINARY ACTION INCLUDING DISMISSAL.
HOURS
HOURS
______ VACATION HOURS REQUESTED
______ COMP TIME REQUESTED
______ PERSONAL LEAVE REQUESTED
______ FLEX TIME REQUESTED
______ SICK LEAVE REQUESTED
______ JURY DUTY
______ PROFESSIONAL DEVELOPMENT**
______
OTHER DUTIES (FIELD TRIPS, ETC.)**
DESCRIPTION NEEDED BELOW
DESCRIPTION NEEDED BELOW
______ PLANNING DAYS (TEACHERS ONLY)
______
BEREAVEMENT LEAVE HOURS REQUESTED
______ ATHLETICS / ACTIVITIES
______ PERSONAL LEAVE DEDUCT SUBSTITUTE
(TEACHERS ONLY)
EMPLOYEE SIGNATURE:
______________________________________________________________________________
APPROVED
BY:
________________________________________________________________________________
**ADDITIONAL HELPFUL INFORMATION / DESCRIPTION:_____________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
D‐22 REV 8‐5‐16 
Original: Office 
Copy For Staff Members 
EMPLOYEE LEAVE REQUEST FORM
NAME:
___________________________________________________________________________________________
DATE(S) OF
LEAVE: ________________________________________________________________________________
REASON FOR LEAVE*: ______________________________________________________________________________
* NOTE: ANY EMPLOYEE WHO FALSELY CERTIFIES IN THIS RESPECT SHALL BE LIABLE FOR DISCIPLINARY ACTION INCLUDING DISMISSAL.
HOURS
HOURS
______ VACATION HOURS REQUESTED
______ COMP TIME REQUESTED
______ PERSONAL LEAVE REQUESTED
______ FLEX TIME REQUESTED
______ SICK LEAVE REQUESTED
______ JURY DUTY
______ PROFESSIONAL DEVELOPMENT**
______
OTHER DUTIES (FIELD TRIPS, ETC.)**
DESCRIPTION NEEDED BELOW
DESCRIPTION NEEDED BELOW
______ PLANNING DAYS (TEACHERS ONLY)
______
BEREAVEMENT LEAVE HOURS REQUESTED
______ ATHLETICS / ACTIVITIES
______ PERSONAL LEAVE DEDUCT SUBSTITUTE
(TEACHERS ONLY)
EMPLOYEE SIGNATURE:
______________________________________________________________________________
APPROVED
BY:
________________________________________________________________________________
**ADDITIONAL HELPFUL INFORMATION / DESCRIPTION:_____________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
D‐22 REV 8‐5‐16 
Original: Office 
Copy For Staff Members