STAFF-Time Off/Sick Time Form
This form is for non-teaching employees at Xavier.
IMPORTANT:
The Business Office will receive your form upon submission.
Employee's Name
*
Employee's Email
*
example@example.com
First Date of Absence(s)
*
-
Month
-
Day
Year
Date
Time Leaving(if a partial day)
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Time Returning(if a partial day)
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Last Date of Absence(s) (only if more than one day)
-
Month
-
Day
Year
Date
Total Days of Absence(s)
*
# of days, ex: 1, 2 , 3 etc.
Supervisor's Name
*
First Name
Last Name
Supervisor's Email (Supervisor will get an email with this information to send to Business Office with their approval)
*
example@example.com
Reason for Time Off/Sick Time
Please select the Non Xavier related reason OR Xavier related reason (which section applies to your request)
Non Xavier related reason (please select that apply)
Vacation
Sick Time (self) return within 24 hours of absence
Sick Time (family) return within 24 hours of absence
Jury Duty (unpaid)
Off Campus Appointment
Bereavement
Time off without pay
Military
Maternity/Paternity (paid through state disability)
Xavier related reason (please check below)
Conference/Colloquium
Athletics
Retreat/Immersion
Off Campus Appointment
Submit
Xavier College Prep
*
Should be Empty: