NYC Department of Sanitation seal

SMART DS-1005

By Bobby Vasireddi

1Employee

2Leave type

3Reason for leave

4Leave start

Pick a date

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5Leave end

Pick a date

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Total hours: —

6Documentation attached

7Charge to

8Balances (optional)

Choose an employee first.

9Supervisor / timekeeper signature (optional)

For this form only, not saved. Date is today.

10Signature

11Attach proof (optional)

Proof

The first proof prints under the DS-1005; more proofs print two per page.

12Email to

Still needed: Leave type, Employee, Reason for leave, Leave start, Leave end

sanitationREQUEST FOR AUTHORIZED LEAVEDS-1005 (1.17)DATE PREPAREDEMPLOYEE'S NAME (LAST, FIRST, M.I.)TITLEBADGE NO.ASSIGNED LOCATIONREFERENCE NUMBERLEAVE STARTLEAVE ENDTOTAL HOURS OFLEAVE REQUESTEDTIMEDATETIMEDATEREASON FOR LEAVESIGNATUREDOCUMENTATIONATTACHEDCHARGETOMedical DocumentationDeath certificateJury duty noticeMilitary ordersOther (Explain in remarks box)Compensatory timeHoliday comp. timeAnnual leaveSick leaveJury duty leaveMilitary leaveLeave without payDeath in familyMaternity or child care leaveOther (Explain in remarks box)BALANCESCOMPENSATORY TIMEANNUAL LEAVE (VAC.)SICK LEAVEC/T FLSANON-FLSAPRE-FLSAHOL-C/TBLOODPRIOR TOLEAVEAFTERLEAVECOMP. TIME BALANCES TO BE USED IN ACCORDANCE WITH FLSA MANUALUNIFORMED SUPERVISOR OR TIMEKEEPER SIGNATUREDATEREMARKS:DISTRICTSUPERINTENDENTORUNIT SUPERVISORRECOMMENDDATEApproveDisapproveSIGNATUREBOROUGH CHIEFDIVISION HEADBUREAU HEADORUNIT HEADApprovedDisapprovedDATESIGNATUREEMPLOYEEOFFICE USERECOMMENDAND APPROVAL
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