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