The Gail & Richard Lumpkin School of Nursing - Absence Request

Use this form to request leave from duties that require the use of benefits.
Submit leave for separate months on separate forms.

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 to Date 1)

Type of Leave (Check all that apply to 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 timeframe you intend to be out of the office here. Example: 12/1/2022 - gone from 1-2:30pm)
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 to Date 2)

Type of Leave (Check all that apply to 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 timeframe you intend to be out of the office here. Example: 12/1/2022 - gone from 1-2:30pm)
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 to Date 3)

Type of Leave (Check all that apply to 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 timeframe you intend to be out of the office here. Example: 12/1/2022 - gone from 1-2:30pm)
Date of Leave (Date 4) Date of Leave (Date 4) / MM / DD YYYY
Type of Leave (Check all that apply for Date 4)

Type of Leave (Check all that apply for 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 timeframe you intend to be out of the office here. Example: 12/1/2022 - gone from 1-2:30pm)
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 for Date 5)

Type of Leave (Check all that apply for Date 5) 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 timeframe you intend to be out of the office here. Example: 12/1/2022 - gone from 1-2:30pm)