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
MM
DD
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
MM
DD
YYYY
Employee Signature * Required