CSUN ID
RECORD #
LAST NAME
FIRST NAME, M.I.
MONTH
YEAR
JOB CODE
DEPT ID
DEPT NAME
DATE
ORIGINAL
DATE
REVISED
PAY PERIOD
Absence Report
PAY PERIOD IS: TIMEBASE CB/ID ALTERNATE WORK WEEK 4/40 9/80 OTHER
EMPLOYEE STATUS NON-EXEMPT S/L & Vac. can be taken in 1-hour increments. EXEMPT S/L & Vac. must be charged in 1-day increments.
Used internally by campus departments to report leave usage.
QUALIFYING NON-QUALIFYING
ABSENCE CATEGORIES
A.W.O.L. (Absence without Leave) COMP TIME TAKEN FURLOUGH JURY DUTY/SUBPOENAED WITNESS LEAVE WITHOUT PAY
Unpaid Leave of 15 Days or Less
INDICATE
31 1 2 3 4 5
HOUR(S) / NO
6 7 8 9 10 11
SYMBOLS
12 13 14 15 16 17
Refer to your Payroll Calendar for correct pay period dates.
18 19 20 21 22 23 24 25 26 27 28 29 30 31 1
TOTAL
DOCK CTO FRL JD DOCK MPA PH SL SLF SLD FL VA
MATERNITY/PATERNITY/ADOPTION PERSONAL HOLIDAY SICK LEAVE
Self
SICK LEAVE - FAMILY
Family Illness
SICK LEAVE - DEATH IN FAMILY
Relationship:
FUNERAL LEAVE
Relationship:
VACATION LEAVE
Submit The Following Leaves to Payroll Administration
MILITARY LEAVE I.D.L. (Industrial Disability Leave (Pending) N.D.I. (Non-Industrial Injury) (Pending) UNION TIME - Reimbursed UNION TIME - Non-Reimbursed
SUBPOENAED WITNESS Fill out information below.
COURT CITY PARTY EXPERT Charge Absence To: NO FEES RECEIVED FEES RETAINED FEES RETURNED TO STATE ABSENCE WHILE SERVING A PROBATIONARY PERIOD PA-634F rev. 08/09 VACATION CTO ABSENCE W/O PAY REASON FOR ABSENCE: MEDICAL APPT. DENTAL APPT.
ML
UTR UTN
CERTIFIED BY EMPLOYEE:
SIGNATURE SIGNATURE
SUPERVISOR APPROVAL:
DEPARTMENT USE ONLY
To the best of my knowledge and belief, the facts stated are accurate and in full compliance with legal requirements.
DATE DATE DATE