Revised: 26 June 2014 IU Human Resources

Employee's Request Form

This form will print on more than one page. A single page PDF is available for download.


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.

Choose one: staffStaff or  hourlyTemporary employee

Have you provided a copy of the active duty orders 30 days in advance? checkboxYes    checkboxNo

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?  checkboxYes    checkboxNo

Has the employee worked 1500 hours in the
last 12 months as of the date leave is requested? checkboxYes    checkboxNo

Is this the first such leave requested this calendar year?  checkboxYes    checkboxNo

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: _________________________________________


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

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

Signature: __________________________________________ Date: ___________________



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