HSRMP Leave Request Form

"*" indicates required fields

Today's Date*

Name*

First Last

Email*

Supervisor Name*

Dr. Lee Revere

Kayla Fernandez Cummings

Dean Virnig

Dr. Yulia Strekalova

Drs. Yulia Strekalova & Lee Revere

Type of Leave*

More than one type of leave may be entered on the application if used during the same period of absence. (e.g. 6 hours of vacation and 2 hours sick leave)

Vacation

Sick

FMLA

Other

Vacation Start Date*

Start Time*

Vacation End Date*

End Time*

Total Vacation Hours*

(Round to quarter-hour increments: .25, .50, .75, as appropriate. If using multiple types of leave, please indicate how you would like your time allocated.)

Sick Start Date*

Start Time*

Sick End Date*

End Time*

Total Sick Hours*

(Round to quarter-hour increments: .25, .50, .75, as appropriate. If using multiple types of leave, please indicate how you would like your time allocated.)

FMLA Start Date*

Start Time*

FMLA End Date*

End Time*

Total FMLA Hours*

(Round to quarter-hour increments: .25, .50, .75, as appropriate. If using multiple types of leave, please indicate how you would like your time allocated.)

Other Start Date*

Start Time*

Other End Date*

End Time*

Total Other Hours*

(Round to quarter-hour increments: .25, .50, .75, as appropriate. If using multiple types of leave, please indicate how you would like your time allocated.)

Notes

Signature*