"Certificate of Illness"
UNIVERSITY OF ARKANSAS AT PINE BLUFF LEAVE REQUEST DATE: With the exception of Sick Leave, this form must be approved before the leave commences. A certificate of Illness Form must be furnished for five or more consecutive days of Sick Leave. I, , respectfully request approval of leave Full Name (Type or Print) from a.m. on until p.m. on . I certify that I have enough leave accrued to cover this request. TYPE OF LEAVE NUMBER OF HOURS EMPLOYEE INFO/SUPERVISOR APPROVAL Vacation Social Security or Colleague ID Number Sick Military Signature of Employee Jury or Witness Duty Leave Without Pay Job Title Compensatory Child Educational Activity* Section Title Other (Specify) Timekeeper Signature Approved by Supervisor *Must not exceed 8 hours during any one calendar year. Revised 6/07-gmb