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									                                             GENOME SCIENCES
                                         REQUEST/REPORT OF LEAVE
                                    PROFESSIONAL OVERTIME EXEMPT STAFF

This form is due by the FIRST working day following the month being reported. Please record the date(s) for each type of
leave which was taken, record hour(s) in the appropriate leave hours used column and indicate the total hours at the bottom.
If no time was taken, put "0" in the total column at the bottom. This form must be signed by the employee and the supervisor.

                                        Please check the box if you did not take any leave.

          Employee Name:

          Leave Month:                                                        Date Submitted:

          Date(s)                       Sick                   Vacation           *Personal             **Other
                                        Leave                  Leave              Holiday               Hours Used
                                        Hours Used             Hours Used         Hours Used

          Total of hours Used
          by Type                              0                    0                     0                    0

          Employee Signature                                                      Date

          Supervisor's Signature                                                  Date

* Employees who have completed 4 months of continuous employment are entitled to 1 personal holiday per
calendar year. If it is not used by the end of the calendar year, it is forfeited.
** "Other" includes leave without pay, bereavement leave, military leave. If "Other" is checked, please identify:

Use of leave assumes sufficient hours have accrued prior to the date of leave. Professional staff level 2 report hours off in
whole day increments. You are paid for completing the work and it is expected that you will work in excess of 40 hours
when needed and have the flexibility to take time off for medical appointments, etc. as they arise.

Please return to Genome Sciences Administration Office, S250                                            Revised 02/11

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