Date:

Employee name:   

Department:

Choose one: Staff or  Hourly employee

Number of days requested off for Military Family Leave:   Date(s) requested:

Relationship to person on military duty:

Have you provided a copy of the active duty orders 30 days in advance? Yes    No

If no, explain:

Employee signature: ____________________________________________________________

For department use only: Please type or print all information. Maintain this original form and a copy of the active duty orders in the department file. Employee should retain a copy.

Employee Eligibility

Has the employee been employed at IU for 12 months?  Yes    No

Has the employee worked 1500 hours in the
last 12 months as of the date leave is requested? Yes    No

Is this the first such leave requested this calendar year?  Yes    No

If no, what were the dates of the last leave? ______________________________

An employee is eligible to take up to 10 workdays of Military Family Leave in a calendar year. How many days of eligibility does the employee have remaining in this calendar year prior to this request? ____________

Approval

Request is approved for _______ number of workdays.

Dates off approved: _________________________________________

DENIAL

Employee does not meet employment eligibility.   Employee has used all 10 workdays this calendar year.

Print name and title of person
approving/denying request: _____________________________________________________

Signature: __________________________________________ Date: ___________________

Staff policy: www.indiana.edu/~uhrs/policies/appointed/military.html
Hourly policy: www.indiana.edu/~uhrs/policies/hourly/military.html