Leave of Absence Request Form

Employee ID Number

Full Name

Primary Department or Business Unit

Current Position Title

Direct Supervisor or Manager Name

Employment Classification

Original Hire Date

Official Work Location

Official Work Email Address

Primary Contact Phone Number

Primary Reason for Leave Request

Total Number of Working Days Requested (excluding weekends and holidays)

Will this leave be taken in partial days or reduced hours?

Is this an intermittent leave request (non-consecutive days)?

Have you taken any leave of absence in the past 12 months?

Expected Return to Work Date

Is there any flexibility with your requested leave dates if business needs require adjustment?

Will you provide medical certification from a qualified healthcare provider?

Will you provide documentation from an educational institution (for professional development leave)?

Will you provide official documentation for bereavement or civic duty leave?

Upload any supporting documentation you currently have available (medical certificates, death certificates, enrollment letters, etc.):

Types of additional documentation you anticipate submitting (select all that apply):

I understand that failure to provide required documentation may result in denial or delay of my leave request.

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

Summarize your current projects, key responsibilities, and their current status:

List all key clients, customers, or external partners who must be notified of your absence:

Name of primary colleague designated to handle your critical duties:

Describe the specific tasks and responsibilities that will be delegated to your designated colleague:

Status of handover documentation preparation:

Select all systems, tools, and access permissions that need to be temporarily modified or transferred:

Will you be available for critical questions or emergencies during your leave?

Have you prepared an out-of-office notification for your email and phone?

Will you have reliable phone and/or email access during your leave?

Emergency Contact Person Full Name

Emergency Contact Relationship to You

Emergency Contact Primary Phone Number

Emergency Contact Secondary Phone Number (optional):

Personal Email Address for Urgent Contact (optional):

Physical Address or Location During Leave (if different from work location):

Do you intend to use accrued paid time off (vacation, personal days, etc.) during any portion of this leave?

Expected Pay Status During Unpaid Leave Portion:

Will you continue to receive benefits (health insurance, retirement contributions, etc.) during your leave?

I acknowledge that I have reviewed the company's leave policies and understand the implications for my compensation and benefits.

Additional comments or questions regarding compensation and benefits:

Anticipated Work Capacity Upon Return:

Will you require workplace accommodations upon return (modified schedule, equipment, accessibility)?

Will you need refresher training or updates on changes that occurred during your absence?

Any other considerations for your return to work:

I certify that all information provided in this form is true, accurate, and complete to the best of my knowledge.

I understand that this request is subject to approval by my supervisor and Human Resources department based on operational needs and policy compliance.

I authorize the company to verify any information provided and to contact relevant parties (healthcare providers, educational institutions) for documentation purposes.

I acknowledge that I have read and understand the company's leave of absence policies and procedures.

Employee Signature

Date and Time of Submission

Supervisor Approval Recommended?

HR Department Final Approval

Final Approval Date: