MSA DEPT. HEAD/INTERPRETING REQUEST FOR LEAVE
(SICK/VAC/Training/FMLA/ETL)
Name
First Name
Last Name
Email:
name@msa.state.mn.us
DEPARTMENT:
*
MSA Department Heads-Terry Wilding
MSA Interpreting Services- Terry Wilding
TYPE OF LEAVE REQUEST(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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