DCH-0043.pdf

This is an Application for Leave form used by the Michigan Department of Health and Human Services, Bureau of Hospitals. The form is designed to document and process employee leave requests for various leave types including administrative leave, annual leave, deferred annual leave, lost time, sick leave, family care leave, union activity, school participation, overtime compensation time, and jury duty. Employees must submit the form in duplicate and provide their employee number, work location, shift information, and specify the beginning and ending dates and times for the requested leave period. Prior approval is required for administrative, family care, lost time, sick, and union activity leave requests, with the exception of sick leave, which does not require advance approval. Employees must sign the application and provide a reason for their leave request.

The form requires completion by an authorized approver who must evaluate the request and indicate whether the leave is approved or disapproved, signing and dating the form accordingly. The scheduling office is responsible for date-stamping the application upon receipt, recording the time received, and noting the receiving staff member's name. The form explicitly states that any falsification of the application may result in employee dismissal, establishing accountability for the accuracy of information provided.