College of Health and Human Services Absence Request Form

Use this form to request leave from duties that require the use of benefits.

Reminder:
If you would like to submit a remote work request, cut and paste the Employee Remote Work Documentation Form link into your browser.

https://www.eiu.edu/president/machform/view.php?id=12478

IGP #191.2 - Remote Work Policy - Short-Term Remote Work

https://www.eiu.edu/auditing/igp/
Name Name First Last
Email
Is this leave being requested as part of an existing FMLA certification?

Is this leave being requested as part of an existing FMLA certification? Yes No
Date of Leave (Date 1) Date of Leave (Date 1) / MM / DD YYYY
Number of hours absent (Date 1):
Type of Leave (Check all that apply - Date 1)

Type of Leave (Check all that apply - Date 1) Sick Leave Vacation (aka "Annual Leave" in Banner) Court Required (Jury Duty) Bereavement
Comments (Date 1)
If using less than 7.5 hours of leave, please indicate the date and time frame you intend to be out of the office here. Example: 12/1/2022 - gone from 1-2:30 pm.
Date of Leave (Date 2) Date of Leave (Date 2) / MM / DD YYYY
Number of hours absent (Date 2)
Type of Leave (Check all that apply - (Date 2)

Type of Leave (Check all that apply - (Date 2) Sick Leave Vacation (aka "Annual Leave" in Banner) Court Required (Jury Duty) Bereavement
Comments (Date 2)
If using less than 7.5 hours of leave, please indicate the date and time frame you intend to be out of the office here. Example: 12/1/2022 - gone from 1-2:30 pm.
Date of Leave (Date 3) Date of Leave (Date 3) / MM / DD YYYY
Number of hours absent (Date 3)
Type of Leave (Check all that apply - (Date 3)

Type of Leave (Check all that apply - (Date 3) Sick Leave Vacation (aka "Annual Leave" in Banner) Court Required (Jury Duty) Bereavement
Comments (Date 3)
If using less than 7.5 hours of leave, please indicate the date and time frame you intend to be out of the office here. Example: 12/1/2022 - gone from 1-2:30 pm.
Date of Leave (Date 4) Date of Leave (Date 4) / MM / DD YYYY
Number of hours absent (Date 4):
Type of Leave (Check all that apply-(Date 4)

Type of Leave (Check all that apply-(Date 4) Sick Leave Vacation (aka "Annual Leave" in Banner) Court Required (Jury Duty) Bereavement
Comments (Date 4)
If using less than 7.5 hours of leave, please indicate the date and time frame you intend to be out of the office here. Example: 12/1/2022 - gone from 1-2:30 pm.
Date of Leave (Date 5) Date of Leave (Date 5) / MM / DD YYYY
Number of hours absent (Date 5)
Type of Leave (Check all that apply - (Date 5)

Type of Leave (Check all that apply - (Date 5) Sick Leave Vacation (aka "Annual Leave" in Banner) Court Required (Jury Duty) Bereavement
Comments (Date 5)
If using less than 7.5 hours of leave, please indicate the date and time frame you intend to be out of the office here. Example: 12/1/2022 - gone from 1-2:30 pm.