Adjunct Leave Request
*Indicates a Required Field
*Employee I.D.:
*Term:
*Division:
Last Name:
First Name:
Leave Hours
Total Number
First Day
of Absence
Last Day
of Absence
Classes Missed
Date
Example:
1/15/10
Subject Catalog Class
Area Number Section
MATH
1314
4001
Location
Time
Day
LSCMontgomery
8:00-8:45 AM
M
# of
Leave
Hours
per
class
Arrangements or
Substitute
.75
Substitute-John Doe
Comments:
Employee Signature:
Date:
Manager Signature:
Date:
To be completed by division staff:
*Will this result in unpaid time?
Amt. to deduct:
Beginning leave balance:
Yes
No
Empl. Record:
Hours Taken:
Complete and submit original to departmental staff
If yes, how many hours?
Ending Leave Balance:
Revised 4/4/11 MMM