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COUNTY OF ALPINE REQUEST FOR This form is to be completed and submitted by each employee to their department prior to every absence. All absences must be pre-approved by the Appointing Authority. Employees returning from sick leave must complete this form immediately upon return to work. □ Vacation Current Balance of Leave Total Wrk Date Time Date Time □ Sick Leave Current Balance of Leave Hours: Total Wrk □ Self Date Time Date Time □ Family □ FMLA Related (Family & Medical Leave Act/California Family Rights Act approval pending notification from Personnel.) □ Bereavement Current Balance of Leave Total □ Comp Time Taken Wrk □ Admin Leave Date Time Date Time □ Holiday ATTACH THE APPROPRIATE DOCUMENTATION TO THIS FORM (ie certification from health provider, memo, etc.) After 3 days of absence chargeable to sick leave, the department head may require a signed statement from the doctor or dentist that the employee was incapacitated during the entire time of sick usage. Date Employee Signature FOR DEPARTMENT USE ONLY Immediate Supervisor Recommendation: □ Approved □ Disapproved Supervisor Signature Department Head Recommendation: □ Approved □ Disapproved Department Head Signature Original: Department Copy: 1-Employee and 1-attached to timesheet submitted to Auditor