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Human Capital Services

Shared Leave Request Form (PER-64A&B)

Fill out the Shared Leave Request Form (PER-64A&B) (pdf)

Filling out the form:

Please read PPM Chapter 4860, Section .040 C, before requesting Shared Leave.  Shared Leave will be granted only for serious, extreme or life-threatening medical conditions.  Though exhaustion of all leave balances is required prior to receiving approved shared leave hours, being out of leave is not a consideration toward approval.

Please complete all items on PER 64-A.  Employees are to describe their own medical condition, which must be supported by the Health Care Provider’s statement.  Please do not enter “See attached” unless the attachment is the employee’s description in a longer form.  The Health Care Provider’s statement cannot substitute for this section. 

Please have your Health Care Provider complete the PER 64-B.  


The PER 64-A should be submitted to the Department/Unit Head in accordance with established procedures for requesting leave.  The employee may submit PER 64-B along with PER 64-A to the Department/Unit Head or directly to the Division of Human Resources.

Departments are to submit the request to the Division of Human Capital Services in a manner that protects the confidentiality of medical information that is protected by law.  (No electronic email or campus mail.)

A shared leave committee reviews the documentation and recommends approval/non-approval to the Provost or appropriate Vice President.  The employee and Department/Unit Head will be notified of the determination as soon as possible.