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Human Resources

Leave Request for Hourly (Non-Exempt) Employees

See instructions for questions about completing this form. 

PERSONAL INFORMATION
DATES/HOURS OF LEAVE — Recorded in 15 minute increments



LEAVE TYPE
Choose ONE

or

*Other Leave: Disaster Leave-DIS, Donor Leave-DON, etc.

REASON
SUPERVISOR
Department TIMEKEEPER



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Is this Family Medical Leave Act related? If yes, refer to the FMLA information under Leave Programs