Work Leave Application

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Last OSU Employee ID (required) Department College/Unit SECTION 2: REASON(S) FOR REQUEST LEAVE DESIGNATION: (Check all boxes that apply) Family and Medical Leave Work Related Injury/Illness Neither PAID LEAVE: Dates Hours Dates Vacation Sick Leave Vacation in place of sick leave Please Specify: Parental Leave Organ Donation Leave Illness/Injury Medical Appointment Compensatory Time Death in Family Hours Self Self Jury Duty/Court Appearance Relationship Military Leave Exposure to Contagious Disease Family Family Total Hours Paid Leave: UNPAID LEAVE: Medical Personal Unpaid Time Off (10 or fewer consecutive working days) Beginning and ending dates Hours Unpaid Leave of Absence (more than 10 consecutive working days) Beginning and ending dates Last date worked Last date in active pay status Hours Return date Extension of Previously Approved Leave of Absence Total Hours Unpaid Leave: University Business/Absence from Worksite (Dates): ADDITIONAL INFORMATION: (Reason for absence, etc.) I understand that approval of this request is contingent upon the availability of adequate leave balances..

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