MSA Health Services Staff REQUEST FOR LEAVE
(SICK/VAC/Training/FMLA/ETL)
Name
First Name
Last Name
Email:
name@msa.state.mn.us
DEPARTMENT:
*
MSA Health Services- Kim Viskocil
TYPE OF LEAVE (CHECK ONLY 1 BOX)
*
SICK- SELF
SICK- SELF APPOINTMENT
SICK- DEPENDENT
SICK- DEPENDENT APPOINTMENT
FMLA
VACATION
FLOATING HOLIDAY
COMP TIME**
TRAINING**
OTHER**
ETL (ONLY IF VAC, FLOATING HOLIDAY AND COMP BALANCES ARE ZERO (0)**
** REASON DOCUMENTED
START OF LEAVE:
END OF LEAVE:
START TIME
Hour Minutes
AM
PM
AM/PM Option
END TIME
Hour Minutes
AM
PM
AM/PM Option
TOTAL HOURS REQUESTED
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