Request for Leave of Absence

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									This Leave of Absence Request form is designed to provide employers with a formal
way for its employees to request a leave of absence. This form also provides
employers with a consistent and efficient method for approving and documenting the
employee’s request. The employee selects the type of leave he or she is requesting,
such as vacation/paid time off, sick leave, military leave, unpaid leave, or other. This
template form should be provided to employees by company managers or human
resources officials.
COMPANY NAME/LOGO
COMPANY ADDRESS                                                                                     INSERT COMPANY LOGO HERE
COMPANY CITY, STATE, ZIP

                               LEAVE OF ABSENCE REQUEST FORM
P LEASE CO MPLETE AND SUBMIT THIS FO R M ALO NG WITH SU P PO R TIN G DO CU M ENTATIO N TO   [ DEP AR TM ENT / CO NTACT NAM E ] [# O F DAYS ]
                                           DAYS PRIO R TO R EQ U ESTED L EAVE STAR T DATE .


                                                   EMPLOYEE INFORMATION
Employee Name (First, Last, Middle Initial):                         Employee ID:                         Employee Department:


Home Address:                                                        City:                                State:             Zip:


Job Title:                                                           Employment Status:


                                                         TYPE OF LEAVE

   Extended Leave of Absence                                            Intermittent Absence

   Unpaid Leave of Absence                                              Paid Leave of Absence

Requested Leave of Absence Start Date:                               Anticipated Leave of Absence Return Date:


                                                    REASON ( S ) FOR LEAVE

   Personal Serious Health Condition (Unrelated to Work)                Adoption
   Personal Leave (Non-Medical Reason)                                  Child-caring (Care for Newborn/Placed Child)
   Care for Family Member                                               Military Leave
   Workplace Injury / Worker’s Compensation                             Union Business Leave (for more than 5 days)
   Pregnancy Leave                                                      Other

                                                        DOCUMENTATION

   Intermittent or reduced work schedule                                A copy of birth certificate/child placement documents
   Medical certification/documentation                                  Other additional supporting documentation

                                              LEAVE OF ABSENCE RESOURCES
Resource Type                                      Dates:
                                         Number of Hours From                Start Date         Through             End Date

Vacation/Paid Time Off (PTO)

Sick Leave

Military Leave

Unpaid Leave

Other

Total

                                               APPROVALS AND SIGNATURES
Employee Name:                                          Signature:                                                   Date:

Supervisor Name:                                        Signature:                                                   Date:

Director Name:                                          Signature:                                                   Date:

HR Name:                                                Signature:                                                   Date:




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COMPANY NAME/LOGO
COMPANY ADDRESS                                                                                                       INSERT COMPANY LOGO HERE
COMPANY CITY, STATE, ZIP

                         LEAVE OF ABSENCE REQUEST FORM

								
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