EMPLOYEE LEAVE REQUEST FORM

"*" indicates required fields

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

(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: 1 GB.

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*

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Employee Leave Request Form