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ARIZONA STATE UNIVERSITY

UNIVERSITY SERVICES
NON-EXEMPT ABSENCE RECORD

Date of Time of
Employee Name: _________________________________ Request: _____________ Request _______AM or PM
Department: ________________________________ ASU ID: ________________________
Does this request interfere with your standby duty or special events assignments? No/NA Yes
Vacation (Employees must request and receive written approval one workday prior to absence.)
Unplanned Vacation (For unanticipated absences-supervisor/designee approval; hours may not exceed work schedule for one-day.)
Extended Vacation (Requests for more than five working days; five workdays advance notice is required prior to first day of absence.)
Sick (One-hour notice required except for occasions when an employee falls ill during his/her scheduled work shift.)
Compensatory Time Use (Request and written approval one workday prior to absence, unless used in lieu of unplanned vacation.)
Bereavement Relationship to Employee: ____________; Funeral: In-state ; Out-of-State (Supervisor/designee verify if eligible.)
Jury Duty (Documentation required to Administrative Services)
Voting
Intermittent FMLA (Must be pre-approved; employee required to provide re-certification every six months to Administrative Services.)
Industrial Injury (Submit Employer’s Report of Industrial Injury forms to Administrative Services.)
Tardy (Employees who report late to their scheduled work shift)
Furlough (Leave without pay)
All hours recorded as hours not worked due to the above shall be documented in one-quarter hour increments on the Non-Exempt Staff Timesheet.
EMPLOYEE REQUEST: Date(s)/Hours of Absence (If five (5) working days or less):
Date____/_____/_____ Hours _____ Date____/_____/_____ Hours _____
Date____/_____/_____ Hours _____ Date____/_____/_____ Hours _____
Date____/_____/_____ Hours _____ TOTAL HOURS ________
If more than five (5) working days:
____/_____/_____ through _____/_____/_____ _____ Hours
____/_____/_____ through_____/_____/_____ _____ Hours TOTAL HOURS ________

_____________________________________________ _________________; OR Supervisor submission on behalf of absent


Employee Signature Date employee. Note: Supervisor provide copy
to employee.

SUPERVISOR SECTION:
Request for Unplanned Vacation Approved
(for unanticipated situations) Absence is recorded as Unexcused Vacation
Request for Vacation Leave Approved Absence is recorded as Unexcused Sick
Request for Sick Leave Approved Absence is recorded as Unexcused Compensatory Time
Request for Compensatory Time Use Approved Absence is No Show/No Call, therefore recorded as
Absence Request is Denied LWOPUA (docked pay) – Initiate Counseling Memorandum
Furlough (Leave without pay) - Approved

______________________________________________________ _____________________________________________
Supervisor/Designee Signature Date

Supervisor’s Comments:________________________________________________________________________________________

IF ABSENCE IS DENIED OR UNEXCUSED STATE REASON: __________________________________________________________

MODIFICATION APPROVAL (if applicable)

Supervisor/
Approval:___________________________________ & ___________________________________ designee must
Supervisor/Designee Signature Date Employee Signature Date maintain a copy
of this
Date __________ Hours __________ document in the
Date __________ Hours __________ Total New Hours: ___________________________ service unit file.

W:\DATA MANAGEMENT SERVICES\UNIVERSITY SERVICES FORMS Rev. 7/1/09