EMPLOYEE LEAVE REQUEST FORM

(Please complete and sign this form every time you will be or have been absent)
Employee Information
Employee Name*
First Middle Last
Phone*
Email*
Today's Date*
MM slash DD slash YYYY
Section 1
I request leave for (choose one):*
- One day or less
- More than one day
Leave Date*
MM slash DD slash YYYY
Leave Time*

: Hours

Minutes

AM/PM
Return Date*
MM slash DD slash YYYY
Return Time*

: Hours

Minutes

AM/PM
Total Days of Leave*
Total Hours of Leave*
Briefly describe the reason for your absence:*
To accommodate an altered or reduced work schedule for medical reasons. Briefly explain why you need a different schedule and what your scheduling needs are (attach a separate sheet if necessary).
Attachment (Optional)
Drop files here or

Max. file size: 100 MB.
Section 2
I am requesting leave for the following purpose(s)*
- Vacation or Personal Day
- Family & Medical Leave
- Sickness (Not Family & Medical Leave Qualifying)
Signature*
Email
This field is for validation purposes and should be left unchanged.

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Employee Information