City of Austin LEAVE REQUEST

Employee Name (last, first, MI) De la Rosa, Sarahi

Employee ID (as required by department) 10157381

Department Police Department

Department Section/Work Group PCO

I request leave as specified by the appropriate code below.

Leave Codes: asterisk ( * ) indicates that certification or documentation may be required

ADL Administrative Leave EVU Exception Vacation Used (old) SCK Sick Leave *
ARL Administrative Recognition Leave HPF Personal Holiday FMLA SKF Sick Leave FMLA*
CRT Court Leave * HPU Personal Holiday Used VCF Vacation Leave FMLA*
CTU Compensatory Time Used LWF Leave Without Pay FMLA VCU Vacation Leave *
E2U Exception Vacation 2 Used LWP Leave Without Pay
EMG Emergency Leave * MIL Military Leave *
Type of Leave Number of Hours From Date: To Date: Beginning Time Ending Time
(code) (0.25, 0.50, 0.75, or full hours only) (mm/dd/yyyy) (mm/dd/yyyy) (indicate a.m./p.m.) (indicate a.m./p.m.)

LWP 10 11/4/2023 11/4/2023 4:00 a.m. 2:30 p.m.

SCK 10 11/5/2023 11/5/2023 4:00 a.m. 2:30 p.m.
LWP 10 11/6/2023 11/6/2023 11:00 a.m. 10:00 p.m.

Reason or Explanation:
Personal

FMLA Qualifying Event  Your own serious health condition.

(Check any that may apply)  Serious health condition of your spouse, child or parent
 Birth or adoption of a child.

If you are absent five or more days due to illness or injury, you are required to bring a return to work release.
Attach other required documentation as applicable, such as military orders, jury service certification, etc.

I hereby certify that the above information is true and correct.

Employee Signature: De la Rosa, Sarahi Date: 10.17.2023

SUPERVISOR REVIEW
 Approved  Denied

Supervisor Signature Date

Director or Designee Signature

HRD/ Leave Request Form, effective 10/1/2004, updated 11/1/2010