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State of Alabama
Unified Judicial System

orm PERS-17(front) Rev.7/95

LEAVE REQUEST AND APPROVAL

FOR AOC USE ONLY

LEAVE COMMENCES

LEAVE TERMINATES

Month

Day

Month

DAY

TOTAL
HOURS

ACTION BY ADMINISTRATOR

LEAVE
CODES

Approved

This Annual leave is / is not Family Medical Leave Act Leave (Check one)

Denied (Explain)

SOCIAL
SECURITY #

Approved

Denied (Explain)

Approved

Denied (Explain)

Approved

Denied (Explain)

Approved for ___________ days

______ leave to be used in addition.

Approved Denied(Explain)

Reason ______________________

Approved
(Limited to 1 day per Calendar Year)

Denied (Explain)

Recommended
Not Recommended

9. All accrued leave exhausted disability
expected to be 5 days or more

Recommended Not Recommended

Physician’s Statement attached

10. Available Sick leave exhausted illness/
Disability has exceeded 150 days

Recommended Not Recommended

DMINISTRATOR

REMARKS

ATE ADC

ACTION

This Sick leave is / is not Family Medical Leave Act Leave (Check one)

his Compensatory leave is / is not Family Medical Leave Act Leave (Check one)

This LWOP leave is / is not Family Medical Leave Act Leave (Check one)

EMPLOYEE
NAME

TYPE OF
LEAVE

REQUESTED

. Annual

. Sick

. Compensatory

. LWOP

. Military

. Administrative

. Personal

8. Educational

9. Advanced

Sick Leave

10. Sick Leave
Reserves

Distribution of Copies: WHITE – Administrator CANARY – Employee

DC APPROVAL (If Required)

APPROVED DENIED

SIGNATURE

APPLICATIONS FOR THE FOLLOWING TYPES OF LEAVE MUST BE FORWARDED TO ADC FOR FINAL APPROVAL

MPLOYEE SIGNATURE AND DATE OF REQUEST

DMINISTRATOR SIGNATURE AND DATE

INSTRUCTIONS FOR COMPLETION OF LEAVE REQUEST FORM

LEAVE REQUEST AND APPROVAL

A. All requests for leave must be submitted to the administrator on a completed Leave Request Form.

B. Before submitting request, employee should check to see that the following items are completed:

orm PERS-17 (back)

1. Name.

2. Social Security Number.

3. Check type of leave requested

4. List dates and hours of request.

5. List total hours of request.

6. Date and sign term.

C. The following types of leave require the approval of the local administrator only:

LEAVE TYPE

SPECIAL INSTRUCTIONS

Annual

Personal leave for any purpose such as vacation, or when sick leave is exhausted.

Sick

Physician’s Statement only if required by administrator.

Sick leave is approved for the following reasons:

a. Personal illness, including immediate family members.

b. Bodily injury.

c. Required physical or dental examination on account of illness.

d. Examinations or treatments by a physician on account of illness (doctor visits).

e. Maternity leave (See also Family Medical Leave Act leave below).

For maternity leave, employee may request one or more of the following leave types:

(1) Sick, for period of disability

(2) Annual, all or part of accumulation

(3) LWOP

LWOP

Administrator completes and forwards signed PERSONNEL ACTION to Personnel Division;

LEAVE REQUEST RETAINED BY ADMINISTRATOR.

Military

Attach copy of orders or other documents; Annual or LWOP used if 21 days military leave exhausted.

Personal

Limited to One (1) day per calendar year. Excludes Baldwin and Mobile counties.

. The following types of leave require the approval of the administrative Director of Courts:

Educational

Course descriptions(s) attached. Administrator may recommend full or partial pay. Forward both copies to personnel Division.

Advanced
Sick Leave

Sick Leave
Reserves

Physician’s supporting statement attached.

Both copies forwarded to Personnel Division.

efer to Chapter V, UJS Personnel procedures Manual for additional information on leave.

Leave Request And Approval

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Alabama state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from eforms.alacourt.gov (2023-03)
Page(s): 2
Fields(s): 157
Average fields per page: 78
Reading Level: Grade 11
LIST Grouping(s): Unknown

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Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

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Leave Request And Approval

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02