UT Southwestern Medical Center
REQUEST FOR LEAVE OR REPORT OF ABSENCE
EMPLOYEE
Employee Name Person Number Job Title Date Submitted
Department Work Location Work Phone
Employee Contact Telephone Number During Absence Name And Telephone Number of Emergency Contact During Absence
ILLNESS OR INJURY RELATED ABSENCE
Absence required for Personal Illness or Injury Medical Appointment Dental Appointment
Absence is related to: Approved FMLA illness or injury Work related injury or illness
Family Member Illness or Injury (Name) ____________________________ (Relationship) _________________
Absence does not exceed three workdays (24-hours or less)
Absence exceeds three workdays (25-hours or more) Physician’s Statement is attached
If absence is for approved intermittent FMLA, please complete ‘Intermittent Absence Record’ and submit with
this request for processing.
If sufficient sick leave accruals are not available to cover absence, please identify leave type requested by
checking appropriate box below under ‘Other Absence’.
OTHER ABSENCE
Request is for Vacation Leave Compensatory Leave Funeral Leave Non-paid Leave
Holiday Worked (Date) _______________________ Other (Identify) __________________________
PERIOD OF ABSENCE
Absence Beginning Date Beginning Time Absence Ending Date Ending Time Total Hours
DOCUMENTATION AND CERTIFICATION
Statement required for report of unscheduled absence or request for non-paid or funeral leave (state name
and relationship of deceased).
EMPLOYEE SIGNATURE
I certify that the information provided by me in this document is, to the best of my knowledge, true and correct
Employee Signature Date
SUPERVISOR
Date Received: Approved Denied (Provide Reason Below)
Supervisor Signature Date
Retain original and return a signed copy to employee
It is each employee’s responsibility to report to work each day as scheduled, on time and ready and able to carry out their
assigned duties and responsibilities. An employee who regularly experiences absences, whether due to illness, injury or
personal reasons, may be subject to disciplinary action that may include termination of employment.
OHR-01/07