Get Musc Request For Leave

MEDICAL UNIVERSITY OF SOUTH CAROLINA REQUEST FOR LEAVE Last Name First Name M. I. Type Leave Requested check appropriate box es. USE A SEPARATE FORM FOR EACH ABSENCE Supplemental Leave Court Optional Holiday Worked on Holiday Military Date of Holiday Administrative Assaulted by a patient/client Bone Marrow Donor Blood Donation Voting Death in Family Name of Deceased Date and Place of Death Relationship Annual Leave Is this Family Medical Leave Yes / No Leave Without Pay Sick Leave Vacation Illness Other - Please explain Child Birth Personal Illness/Accident Illness in Family AMOUNT OF ADMIN. LEAVE REQUESTED. MEDICAL UNIVERSITY OF SOUTH CAROLINA REQUEST FOR LEAVE Last Name First Name M. I. Type Leave Requested check appropriate box es. USE A SEPARATE FORM FOR EACH ABSENCE Supplemental Leave Court Optional Holiday Worked on Holiday Military Date of Holiday Administrative Assaulted by a patient/client Bone Marrow Donor Blood Donation Voting Death in Family Name of Deceased Date and Place of Death Relationship Annual Leave Is this Family Medical Leave Yes / No Leave Without Pay Sick Leave Vacation Illness Other - Please explain Child Birth Personal Illness/Accident Illness in Family AMOUNT OF ADMIN* LEAVE REQUESTED. HRS* AMOUNT OF ANNUAL LEAVE AMOUNT OF LEAVE WITHOUT PAY AMOUNT OF SICK LEAVE DATE S FROM TO TIME S FROM AM/PM TO AM/PM Requires supporting documentation Placement for Adoption Foster Care Medical Appointments 3 days or less more than 3 days May require administrative approval and/or medical certification SUPERVISOR APPROVAL EMPLOYEE SIGNATURE --------------------------------------------------------------------------------------------------------------------------------------------------- USE THIS SECTION FOR FAMILY MEDICAL LEAVE ACT FMLA APPROVALS ONLY I hereby certify that the above named employee meets the requirements for FMLA and that this leave is approved* Department Head Signature HRM Approval FOR DEPARTMENT USE ONLY FOR PAYROLL LEAVE RECORD KEEPING DATE LEAVE RECORDED LEAVE TYPE ANNUAL SICK ADMIN* INITIALS. USE A SEPARATE FORM FOR EACH ABSENCE Supplemental Leave Court Optional Holiday Worked on Holiday Military Date of Holiday Administrative Assaulted by a patient/client Bone Marrow Donor Blood Donation Voting Death in Family Name of Deceased Date and Place of Death Relationship Annual Leave Is this Family Medical Leave Yes / No Leave Without Pay Sick Leave Vacation Illness Other - Please explain Child Birth Personal Illness/Accident Illness in Family AMOUNT OF ADMIN* LEAVE REQUESTED. HRS* AMOUNT OF ANNUAL LEAVE AMOUNT OF LEAVE WITHOUT PAY AMOUNT OF SICK LEAVE DATE S FROM TO TIME S FROM AM/PM TO AM/PM Requires supporting documentation Placement for Adoption Foster Care Medical Appointments 3 days or less more than 3 days May require administrative approval and/or medical certification SUPERVISOR APPROVAL EMPLOYEE SIGNATURE --------------------------------------------------------------------------------------------------------------------------------------------------- USE THIS SECTION FOR FAMILY MEDICAL LEAVE ACT FMLA APPROVALS ONLY I hereby certify that the above named employee meets the requirements for FMLA and that this leave is approved* Department Head Signature HRM Approval FOR DEPARTMENT USE ONLY FOR PAYROLL LEAVE RECORD KEEPING DATE LEAVE RECORDED LEAVE TYPE ANNUAL SICK ADMIN* INITIALS.