Department of Corrections

 

AUTHORIZATION FOR LEAVE AND OVERTIME REQUEST FORM

(Leaves not requiring Department of Personnel approval)

 

TO SUPERVISOR (PRINT):________________________________________________                        DATE___________________

 

I, ______________________________________________________________________,   REQUEST TO BE GRANTED

                                EMPLOYEE’S NAME (PRINT)

                                                                                                                       AM                                                                    AM

_______ DAY(S)  ________ HOUR(S)            FROM: _________  PM   __________        TO: __________   PM  __________

                                                                                                    TIME                     DATE                            TIME                        DATE

 

CHECK TYPE OF LEAVE:

 

ANNUAL (UAL) _______;   SICK (USL) _______;   FAMILY SICK (UFSL) (indicate relationship in remarks below) _______;

 

COMPENSATORY (UCT) _______;   LEAVE WITHOUT PAY (ULWOP) ______;   ADMINISTRATIVE (UADM) _______;

 

FAMILY DEATH (UFD) _______;   CIVIL (UCIV) _______;   MILITARY (UMIL) _______.

 

In the event that leave used exceeds available leave, you will be placed on Leave Without Pay.

 

Request authorization to work Overtime/Comp. Time:  DATE: ___________________ HOURS: ________________

 

Remarks:___________________________________________________________________________________________________

___________________________________________________________________________________________________________.

 

                                                                                                Approved By:

 

__________________________________                 ________________________________________   __________________

Employees Signature                                                                           Supervisors Signature                                                         Date

 

Authorization       (     ) Granted

                (     ) Not Granted

 

Comments:                                                                                            _______________________                          __________________

                                                                                                                Signature                                                                               Date

                                                                                                                Appointing Authority

                                                                                                                Or Authorized Representative

 

 

I, the undersigned, a duly authorized physician, do hereby certify that _______________________________________________, was

 

under my care from _________________, 20_______, to ________________________, 20 _______, inclusive and during that period

 

was wholly incapacitated for official duty.  This certification is given with the full knowledge of the fact that will be used for

 

executive action.

                                                _____________________________                            __________________

                                                                                                Signature of Physician                                                        Date

 

IMPORTANT:  Applications for sick leave must be transmitted immediately, and in no case later than two days after return to duty.  If a physician was not employed, the reason for absence must be stated in the “remarks” section of this form.  Applications for leave must be submitted and authorized in advance except in case of emergency when leave could not be anticipated.  In case of an absence of more than three (3) working days, a physician’s certificate maybe required when requested.