Employee: Complete this section online and print. Submit the form to the department supervisor. Retain a copy for yourself. The original form and a copy of the active duty orders are maintained in the department file.
Number of days requested off for Military Family Leave:
Relationship to person on military duty:
Have you provided a copy of the active duty orders 30 days in advance?
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.
Has the employee been employed at IU for 12 months? Yes
Has the employee worked 1500 hours in the
last 12 months as of the date leave is requested?
Is this the first such leave requested this calendar year? Yes
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? ____________
Request is approved for _______ number of workdays.
Dates off approved: _________________________________________
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
Form updated: 11 July 2007
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