LSU Health Sciences Center New Orleans Campus

LSU Health Sciences Center – New Orleans Campus Application for Leave

Agency:______

Employee Name ______From: _____ AM ____PM To: _____ AM _____PM

I request ______hours of leave Date: ______Date: ______

Chargeable Leave Request [ ] Annual FMLA: [ ] Self [ ] Family [ ] Unpaid [ ] Sick LWOP [ ]

Non-Chargeable Leave Request [ ] Funeral EDUCATIONAL: [ ] Job Related SPECIAL: [ ] Act of God Office Closure [ ] Jury Duty MILITARY: [ ] Active [ ] Physical [ ] Civil Air Patrol American Red Cross [ ] Hazard Duty (law enf) [ ] Training (15 days/yr) [ ] Voting Emergency Civilian [ ] Other ______(Explain in “Comments” Section)

Comments:

______I CERTIFY THAT MY ABSENCE FROM DUTY WAS FOR THE REASON NOTED ______Employee Signature Date Approved by and Title

______

______Leave Definitions Absence Leave Request: LWOP: Leave without Pay SPECIAL Annual: Leave with pay granted an employee for the FMLA: (Family and Medical Leave Act) approved Act of God: Appointing authority determines the purpose rehabilitation, restoration and maintenance of work absence available to eligible employees for up to 12 employee is prevented by an act of God from efficiency, or transaction of personal affairs. weeks of leave per year for certain family and medical performing duty. Sick: Leave with pay granted an employee who is reasons. Civil Air Patrol: A member of Civil Air Patrol ordered suffering with a disability which prevents him from Self: For employee’s own serious health condition. to perform duty with troops or participate in field performing his usual duties and responsibilities or who Family: An immediate family member (spouse, child exercises or training. Leave shall not exceed 15 requires medical, dental or optical consultation or or parent with a serious health condition). working days in any one calendar year. treatment. Unpaid: When paid leave (annual/sick) is exhausted or Emergency Civilian: Performing emergency civilian cannot be used under specific circumstances. duty in relation to national defense. Non-Chargeable Leave Request: Office Closure: Leave granted due to local conditions Funeral: Leave granted when attending the funeral or MILITARY which prevented the employee from attending work. burial rites of a parent, step-parent, child, step-child, Active: Leave granted when called to active military American Red Cross: Leave granted for a period not to brother, step-brother, sister, step-sister, spouse, mother-in- duty. exceed 15 work days in any calendar year to participate law, father-in-law, grandparent, or grand-child; provided Training: Annual training or active duty for training in American Red Cross relief services in Louisiana for such time off shall not exceed two days on any one (weekend drills). disasters designated as Level III or above in the Am Red occasion. Physical: Leave granted to conduct mandatory Cross Regulations and Procedures. Must be certified as Jury Duty: Summoned to perform jury duty. physical to enlist in military. a Trained Disaster Volunteer and approved by Hazard Duty (law enf): Granted when an employee appointing authority. engaged in law enforcement work is disabled while in the EDUCATIONAL Voting: Leave granted when voting in a primary, performance of duty of a hazardous nature and because of Job Related: Leave granted to attend a course that is general or special election which falls on regular such disability is unable to perform his usual duties. (Civil relevant to job. scheduled work days, provided not more than two hours Service Rule 11.21.1) of leave shall be allowed to vote in the parish where he OTHER is employed and not more than one day to vote in Any other special or non-chargeable leave request as another parish. provided in Chapter 11 of the C.S. Rules