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                                                                                                                                   FLSA EXEMPT?
      NAME            Please Print or Type                                                University ID#

                Dates of Leave: Beginning                                                    Ending

Please forward the approved original of this form to the Payroll Office the week after the leave is taken
                                                                          Payroll Hours
                    TYPE OF LEAVE                           Reference      Code Taken 100ths                               Conversion Chart
Vacation Leave- Accrued                                       PIM 11        170                               Minutes=     Hundreths Minutes=         Hundreths
Donated Vacation Leave- Family Member Donation                PIM 29        271                                    5          0.08          35           0.58
Donated Vacation Leave- NonFamily Member Donation             PIM 29        270                                   10          0.17          40           0.67
Sick Leave- Accrued                                           PIM 29        180                                   15          0.25          45           0.75
Donated Sick Leave- Family Member Donation                    PIM 29        281                                   20          0.33          50           0.83
Donated Sick Leave- NonFamily Member Donation                 PIM 29        280                                   25          0.42          55           0.92
Bonus Leave- Employee                                         PIM 29        190                                   30          0.50          60           1.00
Donated Bonus Leave- Family Member Donation                   PIM 29        291
Donated Bonus Leave-NonFamily Member Donation                 PIM 29        290                               Note: You may qualify for FML if this leave is
                                                                                                              for an illness or health condition that prevents you
Leave Without Pay                                             PIM 05        420
                                                                                                              from performing the functions of your job for 3
Community Service Leave                                       PIM 46        171
                                                                                                              consecutive days; for the birth adoption, or foster
Military Leave                                              SPM Sec. 5                                        care placement of a child with your family; or for
Civil Leave                                                 SPM Sec. 5                                        caring for a child, spouse, or parent with a serious
Advanced Vacation Leave                                       Pim 03       30 V                               health condition.
Advanced Sick Leave                                           Pim 03        30 S                              See PIM 9 for more details.


 Employee Signature:                                                                                  Date:

 Supervisor's Signature:                                                                              Date:
                   Supervisor's signature indicates approval of the above leave request
                                                                                                                           Date Processed by Payroll:
Supervisor: Does this leave cover all or part of an approved Family and Medical Leave?
                                                         Yes         No

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