Maintenance Department
Responsibility Pay Request
Date: _____________________
To:
Jimmy Brimmer
Pay for: __ vacation __ sick leave __ comp __ pers leave __ flex
Other: ____________________________________________________
Replacing : ________________________________________________
Name and Title
Employee: _____________________________ SS#: ________________
Date(s) with reason listed for each day:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
_________________________________________________
_________________________ has performed a significant portion of the
(Name)
responsibilities of ________________________________ for the majority
(Name)
of the shift(s) and/or date(s) indicated.
__________________________ ___________________________
Coordinator/Supervisor Signature
Director Signature
This form must be submitted to the Maintenance Payroll/HR Office as soon as
the situation is known. Article 5 of the Agreement: 5 consecutive days; 5 days in
3 months; or 8 days in school year.
Uncontrolled Copy
Created: 01/01/2005 Revised: 12/2/2013