Employee Extended Time Off Request Form

Employee ID Number

Full Name

Primary Department or Business Unit

Current Role or Job Title

Direct Manager Name

Primary Contact Email During Leave

Primary Contact Phone Number During Leave

Is your personal contact information in the HR system up to date?

Please provide the updated details and indicate which information needs to be changed in the system:

Emergency Contact Name (Different from primary contact)

Emergency Contact Relationship

Emergency Contact Phone Number

Primary Leave Type Classification

Sabbatical Purpose and Professional Development Plan:

Reason for Unpaid Leave and Financial Acknowledgment:

Medical Leave Details (Privacy-protected):

Leave Start Date

Start Time on Leave Start Date (if partial day)

Leave End Date

End Time on Leave End Date (if partial day)

Total Number of Working Days Requested

Is this leave request foreseeable (i.e., planned in advance rather than emergency)?

How many calendar days of advance notice are you providing?

Explain the unforeseen circumstances requiring emergency leave:

Does your requested leave period overlap with any known organizational blackout or restricted dates?

Describe the business-critical reason for the blackout period and your mitigation plan:

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

Current Available PTO Balance (in days)

Current Available DTO Balance (in days)

Number of PTO Days You Wish to Apply to This Request

Number of DTO Days You Wish to Apply to This Request

Estimated Gross Salary Continuation During Paid Leave Portion

Leave Balance Utilization and Unpaid Days Calculation

Will any portion of this leave be unpaid?

Total Unpaid Days

If unpaid leave exceeds 30 consecutive days, do you understand that you may be responsible for the employer portion of benefit premiums?

Describe your arrangement for remitting benefit premium payments:

Does this extended leave impact your eligibility for any upcoming bonus or commission payments?

Detail the affected incentive programs and your understanding of the pro-rata calculation:

Primary Coverage Colleague Name

Primary Coverage Colleague Role

Summary of Coverage Plan and Delegation Strategy

Key Projects, Tasks, and Handover Status

Will you remain accessible for critical or time-sensitive decisions during your leave?

Specify contact method, expected response time, and types of issues that warrant contact:

Have you scheduled and conducted a formal handover meeting with your coverage colleague(s)?

Scheduled Handover Meeting Date

Which stakeholder groups have been proactively notified of your upcoming absence?

Manager Name Who Will Handle Notifications:

Direct Manager Approval Name

Does your leave exceed 21 consecutive working days?

Department Head or Director Approval Name

Does your leave exceed 60 consecutive calendar days?

Executive Leadership or VP Approval Name

HR Business Partner or Representative Name

Are you a people manager with direct reports?

Describe your plan for managing team performance reviews, one-on-ones, and ongoing development during your absence:

Additional Functions That Must Be Notified (Select all that apply)

Will your health, dental, and other insurance benefits remain active during the entire leave period?

Specify which benefits will lapse and your plan for alternative coverage:

Do you have any company-owned equipment (laptop, phone, test devices) that must be returned before leave begins?

Equipment Return Inventory

Will you retain possession of any company devices during your leave?

Justify business necessity for retaining equipment and confirm secure storage:

Should your system access (VPN, email, internal tools) be suspended during the leave period?

Specify which systems must remain accessible and the security rationale:

Will you be located in a different geographical region during your leave?

Provide location details and confirm understanding of international security protocols:

Is this leave request related to a qualifying life event (e.g., adoption, serious family illness, natural disaster)?

Describe the life event without disclosing confidential details beyond what is necessary for processing:

Will you be traveling internationally during your leave?

List destination countries and confirm registration with organizational travel safety program:

Do you have any court-ordered obligations (jury duty, witness appearance, legal proceedings) during this period?

Provide court documentation details and expected time commitment:

Is this an urgent or emergency leave request submitted with less than 5 business days notice?

Explain the emergency circumstances and why advance notice was not possible:

Alternative Contact Person for True Emergencies (if primary unreachable)

Any Additional Notes or Special Considerations for HR Review

Is a medical certificate or healthcare provider documentation required for this leave type?

Upload Medical Certificate or Healthcare Provider Documentation

Is proof of entitlement required (e.g., sabbatical eligibility, parental leave qualification)?

Upload Proof of Eligibility Documentation

Are you providing any additional supporting documents (travel itinerary, court summons, etc.)?

Upload Additional Supporting Documentation

Documentation Submission Tracker

Do you anticipate providing updated documentation (e.g., revised medical certification) during your leave?

Describe the expected updates and submission timeline:

Confirmed Return to Work Date

Do you wish to request a phased return-to-work schedule (e.g., part-time hours for initial weeks)?

Detail your proposed phased return schedule including duration and hours:

Will you require any workplace accommodations or modifications upon return (e.g., ergonomic adjustments, modified duties)?

Specify required accommodations and supporting medical documentation if applicable:

Do you anticipate needing a reorientation or refresher training session to catch up on organizational changes?

Identify key areas where reorientation would be beneficial:

Return-to-Work Meeting Agenda Items (to discuss with manager upon return)

Will your role, responsibilities, or team assignment change upon return?

Describe the expected changes and transition plan:

Updated Personal Contact Information for Use After Return (if changed)

I certify that all information provided in this form is accurate and complete to the best of my knowledge. I understand that intentional misrepresentation may result in disciplinary action up to and including termination.

I acknowledge that I have read and understand the organizational Leave of Absence Policy and agree to abide by all terms and conditions outlined therein.

I confirm that I have provided the minimum required advance notice per policy (or documented emergency circumstances) and have engaged in good-faith planning discussions with my manager.

I understand that approval of this request is contingent upon business needs, adequate work coverage, and final authorization from my manager and HR. Submission does not guarantee approval.

I acknowledge that benefits continuation is subject to policy terms, timely premium payments (if applicable), and that failure to return from leave may trigger repayment obligations for employer-paid premiums.

I agree to provide updated medical or eligibility documentation if requested and understand that failure to do so may result in leave denial or revocation of approval.

I commit to notifying HR and my manager immediately if my return date changes or if I need to extend/curtail my leave for any reason.

Employee Signature

Form Submission Date and Time