Mercer Medicine Leave Request

Mercer Medicine

Department Leave Request/Approval Form for Faculty/Provider
Leave Request must be submitted to Supervisor 10 working days in advance.

(Leave is not approved until signed by Department Chair.)
Date

MonthDayYear
Date
Title*
Employee Name:*

First NameLast Name
Email*
example@example.com
Location*
Request for Leave (Please indicate type):*
Is this leave all day:*
Starting Date*

MonthDayYear
Date
Ending Date*

MonthDayYear
Date
Start time to block:

Hour Minutes

AM/PM Option
End time to block:

Hour Minutes

AM/PM Option
Total number of hours being requested:
Please remember to also enter your vacation time in WorkDay.
Sick Leave
Please indicate type.
Unpaid Leave
Purpose of unpaid leave
If required covering physicians name:*
Covering physicians email address:*
example@example.com
Comments:
File Upload

Cancelof
Should be Empty: