PTO form

Employee name

E-mail address @lcn.edu

Supervisor(s) (check all that apply):

President Mingee

Gina Brassard

Connie Young

Karlee Thomen

Date(s)

Provide number of hours for each type of leave:

PTO (staff only)

Mental Health (staff only) (refer to policy)

EIB (staff only) (refer to policy)

Personal business (faculty only)

Sick days (faculty only)

Bereavement (refer to policy)

Jury duty - email copy of summons (refer to policy)

Leave of absence without pay (refer to policy)

Flex time leave (salary staff only - 4 hours per day max)
Please indicate the date(s), hours, and source of flex-time

Overtime (hourly staff only) (must be pre-approved by President)

Notes

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