Department of Psychiatry
Staff Leave Request
REV.02/2004
Date: _________________
It is mandatory to have the Date, Time, Hours and/or Day filled in. Please have your
supervisor sign your leave request(s).
ANNUAL LEAVE						SICK LEAVE
Date	Time out	Time in	Hour(s)	Day(s)		Date	Time out	Time in	Hour(s)	Day(s)
Total:						Total:
PROFESSIONAL/OTHER LEAVE						COMP TIME LEAVE
Date	Time out	Time in	Hour(s)	Day(s)		Date	Time out	Time in	Hour(s)	Day(s)
Total:						Total:
Coverage provided by:			_____________________________________________________
Employee name:
			Print				Signature
Supervisor name:
			Print				Signature