DIXIE STATE COLLEGE

EMPLOYEE LEAVE REQUEST FORM

NAME _____________________________ DEPARTMENT ____________________

1.) Check the month(s)    2.) Circle the date(s)    3.) Put the code and number of hours

___JAN ___ JUL 1 ___ 7 ___ 13 ___ 19 ___ 25 ___ 31 ___
___ FEB ___ AUG 2 ___ 8 ___ 14 ___ 20 ___ 26 ___

 

___ MAR ___ SEP 3 ___ 9 ___ 15 ___ 21 ___ 27 ___

 

___ APR ___ OCT 4 ___ 10 ___ 16 ___ 22 ___ 28 ___

 

___ MAY ___ NOV 5 ___ 11 ___ 17 ___ 23 ___ 29 ___

 

___ JUN ___ DEC 6 ___ 12 ___ 18 ___ 24 ___ 30 ___

 

Codes: V=Vacation C=Contract Hours S=Sick PP=Personal Preference

J=Jury B=Bereavement M=Military FM=Family Medical Leave

EMPLOYEE SIGNATURE ____________________________ DATE _________________

SUPERVISOR APPROVAL ___________________________ DATE _________________

If not approved, please explain ________________________________________________

Return Original to Employee
Copy to Supervisor