Leave Request Form

Leave Request Form
Employee Name*

First NameLast Name
Type of leave requested*

FMLANon FMLA
School / Location*
Supervisor*
Reason for leave*
Provide details/description as appropriate*
If this leave requires a long term substitute for your position, indicate who the substitute will be.
Length of Leave Request*
You can find the number of personal and sick days you have available on the iVisions Web Portal.
How many personal days do you have available to use?*
How many sick days do you have available to use?*
How many personal days do you wish to use for this leave request?*
How many sick days do you wish to use for this leave request?*
The remainder of days will be leave without pay.
Date leave to start*

MonthDayYear
Date
Date of anticipated return to work*

MonthDayYear
Date
Date*

MonthDayYear
Date
Email (Enter your email twice for confirmation)*

Confirmation Emailexample@example.com
Please verify that you are human*
Should be Empty: