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Leave Time Request Form - Roesch
Employee Information
Employee Name: *
Employee E-mail:*
UFID #:*
Supervisor
Luiz Roesch
Role with the department
Academic personel
Teams
USPS
OPS
FMLA-Qualifying Event?
No
Yes
Leave Dates
Leave Date:*
Leave Time:
Return Date:*
Leave Time:
Type and Amount of Leave
Total Hours of leave:*
Type of Leave
None
Vacation
Sick (Employee)
Sick (Family)
Workplace Injury Leave (First 40 hours of work-related injury)
Regular Compensatory Leave (Exempt USPS only)
Special Compensatory Leave(salary payments NOT eligible)
Overtime Compensatory Leave
Personal Holiday (Permanent USPS)
Type and Amount of Administrative Leave
None
Jury duty/court witness
elections
Military training
National Guard
Military exams
Natural disaster
Civil disorder
Athletic competition
Formal investigation
Disabled Veteran treatment
Death in immediate Family
Extraordinary circumstances
Florida Disaster volunteer
Type of FMLA Event (If Applicable)
None
Parental leave
Medical leave
Military, long-term
Worker’s compensation
Leave Without Pay
None
Authorized
Unauthorized
December Vacation Leave Cash-Out
None
Hours cashed out
Personal Leave Days
None
Used December – during the holiday closing period
Used December 2 – June 30
I certify that my absence is for the reason stated above and I understand that my absence will count toward my 12 workweeks of FMLA entitlement if absence is for a qualifying event.
Electronic Signature:
Date
Submit
