Formal Intake Authorization for Extended Leave Requests

1. Section 1: Employee Profile & Leave Duration Metadata

This section captures essential employee identification and leave request fundamentals. All fields marked mandatory must be completed to process your request.

Employee ID Number

Full Legal Name

Current Department/Division

Current Job Title

Original Hire Date

Total Years of Service

Current Employment Status

Full-time

Part-time

Contractor

Other

Please specify other employment status

Sabbatical Policy Note: Personal sabbaticals typically require minimum service thresholds and may have specific eligibility criteria. Your request will be evaluated against established policies.

Please provide detailed description of leave type

Proposed Leave Start Date

Proposed Leave End Date

Total Requested Leave Duration in Calendar Days

Total Requested Leave Duration in Months

Primary Reason for Requesting Extended Leave

Detailed Description of Leave Purpose and Planned Activities

Primary Location During Leave Period

Have you taken any extended leave (30+ consecutive days) in the past 24 months?

Yes

No

Previous Extended Leave History

	Leave Start Date	Leave End Date	Leave Type	Reason Summary
	A	B	C	D
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Emergency Contact Name During Leave

Emergency Contact Relationship

Emergency Contact Phone Number

Emergency Contact Email Address

Preferred Communication Method for Official Correspondence During Leave

2. Section 2: Business Impact, Coverage Plan & Work Handover Rationale

This section assesses the operational implications of your absence and requires detailed planning for business continuity. Incomplete handover plans may result in request deferral.

Summary of Current Key Responsibilities and Duties

Active Projects & Initiatives Status

	Project Name	Current Status	Criticality Level (High/Medium/Low)	Expected Completion Date	Stakeholder(s)	Your Role on Project
	A	B	C	D	E	F
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Business Impact Assessment - Please rate the potential impact of your absence on the following dimensions:

	No Impact	Minimal Impact	Moderate Impact	Significant Impact	Severe Impact
Team Productivity & Morale
Project Delivery Timelines
Client/Customer Service Continuity
Revenue Generation Activities
Strategic Initiative Progress
Knowledge & Expertise Gap

Do you have a formal coverage plan identifying colleague(s) who will assume your duties?

Yes

No

Coverage Plan Details

	Colleague Name	Colleague Role	Specific Duties to be Covered	Coverage Start Date	Coverage End Date	Has the colleague formally agreed?
	A	B	C	D	E	F
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Explain how critical functions will be managed without a designated coverage plan

Specify what remains to be documented and timeline for completion

Target completion date for knowledge transfer

Justify why knowledge transfer has not commenced and provide immediate action plan

Upload Knowledge Transfer Documents, Process Manuals, or Handover Notes

Choose a file or drop it here

Will client or external stakeholder communication be required during your leave?

Yes

No

Detail the communication plan including who will communicate, frequency, and key messages

Critical Business Dates & Milestones During Leave Period

	Critical Date	Event/Milestone	Your Required Action (if any)	Contingency Plan
	A	B	C	D
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Detailed Work Handover Plan & Timeline

Have you discussed this leave request with your direct manager prior to submission?

Yes

No

Summarize manager's preliminary feedback and any concerns raised

Explain why prior discussion did not occur and how you plan to address potential business impacts

Return-to-Work Transition Plan (how you will re-integrate upon return)

3. Section 3: Health Insurance, Benefits Continuity & Pension Impact Assessment

Extended unpaid leave may impact your benefits eligibility and coverage. This section ensures you understand and acknowledge these implications. Consult with Benefits Administration if clarification is needed.

Do you wish to continue health/medical insurance coverage during your leave?

Yes

No

Who will be responsible for premium payments?

Employee pays 100%

Employee pays portion, company subsidizes

Company continues full payment

Other arrangement

Specify payment arrangement details

Describe your alternative health coverage plan during leave

I acknowledge and understand that pension plan contributions will be suspended during unpaid leave periods and this may affect my retirement benefits calculation

Will you continue to accrue vacation, sick leave, or other paid time off during your unpaid leave?

Yes

No

Specify accrual rates and any policy deviations approved

Note: Standard policy prohibits PTO accrual during unpaid leave periods. Any exceptions require executive approval.

Compensation Status During Leave

100% Unpaid

Partial Pay (e.g., using PTO balance)

Deferred Compensation

Other

Will you require payroll deductions for benefits premiums during leave?

Yes

No

Payroll Deduction Schedule

	Benefit Type	Monthly Premium	Deduction Frequency	Deduction Start Date
	A	B	C	D
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Will benefits re-enrollment be required upon return?

Yes

No

Detail the re-enrollment process and any waiting periods

Do you have dependents covered under your current benefits plan?

Yes

No

Describe impact on dependent coverage during leave period

Will you require international health coverage during leave?

Yes

No

Specify countries of residence and required coverage scope

I understand that equity vesting schedules may be paused or impacted during unpaid leave and I have reviewed the equity plan documents

Additional Benefits-Related Questions or Concerns

4. Section 4: Intellectual Property, Non-Compete & Re-Onboarding Conditions Review

This section addresses legal and compliance obligations during your leave. Your continued adherence to company policies is mandatory regardless of employment status during leave.

I reaffirm my commitment to uphold all confidentiality and non-disclosure agreements executed during employment

I understand that all intellectual property created during my leave period, even if unrelated to company business, must be disclosed and may be subject to company IP claims per my employment agreement

Will you engage in any external employment, consulting, or business activities during your leave?

Yes

No

Provide full details of external activity including organization name, nature of work, and potential conflict of interest assessment

Note: Any change in circumstances regarding external employment must be immediately reported to HR and Legal.

Do you hold any active non-compete or restrictive covenant agreements with the company?

Yes

No

Describe how you will ensure compliance during leave, particularly regarding new skills acquired or industry exposure

Provide justification for retaining equipment and confirm security protocols

Specify equipment retention arrangement and security measures

Will your system and building access be revoked during leave?

Yes

No

Confirm understanding that re-access will require new security clearance upon return

Justify why access must be maintained and describe monitoring protocols

Will you require a formal re-onboarding program upon return?

Yes

No

Explain your plan for self-guided re-integration

I agree to return all company confidential information and materials immediately if requested during leave

Provide commitment timeline for return notification

Are there any pending legal or compliance matters that may affect your leave?

Yes

No

Describe the matter and how it will be managed during leave

Will you require re-certification or re-validation of professional credentials upon return?

Yes

No

List credentials and timeline for re-certification

I acknowledge that failure to comply with IP, confidentiality, or non-compete obligations during leave may result in disciplinary action up to and including termination

Additional Legal or Compliance Considerations

5. Section 5: Direct Manager & Chief Human Resources Officer (CHRO) Clearance Sign-Off

This final section is reserved for management and HR authorization. Employee applicants should not complete this section.

DIRECT MANAGER ASSESSMENT

Direct Manager Name

Manager Review Date

Manager Risk & Impact Assessment


Overall Business Continuity Risk
Adequacy of Coverage Plan
Completeness of Knowledge Transfer
Employee Readiness for Leave
Team Preparedness
Client Impact Severity

Specify all conditions for approval

Explain rationale for deferral and required conditions to re-apply

Explain rationale for denial

Explain escalation reasons

Manager Comments & Additional Observations

Direct Manager Digital Signature

HUMAN RESOURCES BUSINESS PARTNER REVIEW

HR Business Partner Name

HR Review Date

HR Compliance Assessment Score (1 = Non-compliant, 5 = Fully Compliant)

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HR Recommendation to CHRO

Support Approval

Support with Conditions

Recommend Denial

Need Additional Information

HR Summary & Risk Analysis

CHIEF HUMAN RESOURCES OFFICER (CHRO) FINAL AUTHORIZATION

CHRO Name

CHRO Decision Date

CHRO Final Decision

Authorize Leave

Authorize with Conditions

Deny Request

Table for Leadership Review

CHRO Conditions & Stipulations

CHRO Denial Rationale & Alternative Options

Explain leadership review requirements and timeline

CHRO Digital Signature

APPEALS & FINAL ACKNOWLEDGMENTS

If your request is denied or approved with conditions you find unacceptable, you may appeal the decision through the standard grievance process outlined in the employee handbook. Appeals must be submitted within 15 business days of receiving this decision.

I acknowledge that I have read and understand all conditions of this leave authorization

I agree to comply with all policies and conditions specified during my leave period

I understand that this authorization may be revoked if business circumstances change materially

Final Acknowledgment Date