"Vacation - Sick Leave Request Form - Georgia Institute of Technology"

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Georgia Institute of Technology
VACATION—SICK LEAVE REQUEST FORM
(OHR Policy Section 2.0)
http://www.admin-fin.gatech.edu/human/attendance/020100.html
This form must be submitted before taking leave.
Sick Leave Exception:
When accident or illness prevents filing a request before using leave, submit this form immediately upon return to work.
PLEASE TYPE OR PRINT
________________________________
___________________
_______________________________
Name
Employee ID# (PeopleSoft)
Work Unit/Department
I request that I be granted PAID VACATION OR SICK LEAVE as follows:
_____
Vacation Leave
(No documentation required. Simply write in: "Vacation" or "Day Off" in space below.)
_____
Sick Leave
(No documentation is required for the first 5 consecutive days*, unless the manager
requests special documentation.
For routine use, simply write in: "Doctor Appointment" or "Illness" or "Injury" or
"Bereavement" in space below.)
NOTE: *Per Board of Regents Policy, a Doctor's certificate is required for Sick Leave use after 5 consecutive days.
NOTE: Time taken as Sick Leave (or Paid or Unpaid Leave of Absence) may be credited against Family Medical Leave Act eligibility.
Please grant this leave request as a result of the following circumstances. (Provide appropriate & adequate details.)
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Give specific times for each type of leave requested and attach appropriate documentation as noted above.
____________________________________
_______________
_________
____________ _
______
Type of Leave Requested
Beginning Date
and
Time
Ending Date
and
Time
____________________________________
_______________
_________
____________ _
______
Type of Leave Requested
Beginning Date
and
Time
Ending Date
and
Time
Employee Signature ___________________________________
Date __
________________________
_________________________________
___________
[ ] Approved
[ ] Disapproved
Supervisor's Signature
Date
If approval is NOT recommended, attach explanation.
_________________________________
___________
[ ] Approved
[ ] Disapproved
Dean, Department Head, AVP or President
Date
(If Required)
If approval is NOT recommended, attach explanation.
VACATION – SICK LEAVE REQUEST FORM
JUNE 2003
Georgia Institute of Technology
VACATION—SICK LEAVE REQUEST FORM
(OHR Policy Section 2.0)
http://www.admin-fin.gatech.edu/human/attendance/020100.html
This form must be submitted before taking leave.
Sick Leave Exception:
When accident or illness prevents filing a request before using leave, submit this form immediately upon return to work.
PLEASE TYPE OR PRINT
________________________________
___________________
_______________________________
Name
Employee ID# (PeopleSoft)
Work Unit/Department
I request that I be granted PAID VACATION OR SICK LEAVE as follows:
_____
Vacation Leave
(No documentation required. Simply write in: "Vacation" or "Day Off" in space below.)
_____
Sick Leave
(No documentation is required for the first 5 consecutive days*, unless the manager
requests special documentation.
For routine use, simply write in: "Doctor Appointment" or "Illness" or "Injury" or
"Bereavement" in space below.)
NOTE: *Per Board of Regents Policy, a Doctor's certificate is required for Sick Leave use after 5 consecutive days.
NOTE: Time taken as Sick Leave (or Paid or Unpaid Leave of Absence) may be credited against Family Medical Leave Act eligibility.
Please grant this leave request as a result of the following circumstances. (Provide appropriate & adequate details.)
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Give specific times for each type of leave requested and attach appropriate documentation as noted above.
____________________________________
_______________
_________
____________ _
______
Type of Leave Requested
Beginning Date
and
Time
Ending Date
and
Time
____________________________________
_______________
_________
____________ _
______
Type of Leave Requested
Beginning Date
and
Time
Ending Date
and
Time
Employee Signature ___________________________________
Date __
________________________
_________________________________
___________
[ ] Approved
[ ] Disapproved
Supervisor's Signature
Date
If approval is NOT recommended, attach explanation.
_________________________________
___________
[ ] Approved
[ ] Disapproved
Dean, Department Head, AVP or President
Date
(If Required)
If approval is NOT recommended, attach explanation.
VACATION – SICK LEAVE REQUEST FORM
JUNE 2003