If you have any questions about this form or HSS's leave policy, please contact your staff specialist by phone at 240-235-5065. Pick your preferred contact method for your response and fill it in here:
YOUR NAME:
OFFICE PHONE:	CELL PHONE:
OFFICE EMAIL:	HOME EMAIL:
CLIENT/ASSIGNMENT*:
NAME OF DIRECT SUPERVISOR*:
SUPERVISOR DIRECT PHONE*:	SUPERVISOR E-MAIL*:
DATE(S) AND TIME(S) OF REQUESTED LEAVE (PLEASE BE SPECIFIC ABOUT TIMES)*:
REASON FOR REQUEST*:
I understand that leave is NOT automatically granted upon completion of this form, and that I may not take leave until I have received authorization from a HSS staffing specialist. Further I understand that it is solely my responsibility to ensure that HSS has received and is processing this request. (* Required)