EMPLOYEE LEAVE REQUEST FORM

"*" indicates required fields

(Please complete and sign this form every time you will be or have been absent)

Employee Information

Employee Name*

Phone*

Email*

Today's Date*

Section 1

I request leave for (choose one):*

One day or less

More than one day

Leave Date*

Leave Time*

Return Date*

Return Time*

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)

Other

Signature*

Name

This field is for validation purposes and should be left unchanged.

Employee Leave Request Form