Shared Leave Request Form

Request Form

Employee Name(Required)

First Last

Employee ID Number(Required)

Department(Required)

Boise State Email(Required)

Phone Extension Number(Required)

Supervisor Name(Required)

First Last

Date of Request(Required)

YYYY

Reason For Request(Required)

Serious illness/Injury of Employee

Death of Employee

Serious illness/Injury of family member

Death of family member

Other

If family member please list name and relationship to employee

Please provide a detailed description of other illness/injury

Employee's expected date of return to work(Required)

YYYY

Employee Signature(Required)