This is a template form that a business can require that its employees use to request
work absences. This form should be used for employee absences that are not within
the Family Medical Leave Act (FMLA). This document can be customized to fit the
needs of the employer. Employers may use this form to track employees' leaves of
absence and to plan accordingly.
Please submit this report to your supervisor when you plan to be out of the office.
NAME: ______________________ AUTHORIZATION: _________________
REASON (Circle) DATE OUT DATE IN
CONFERENCE _________________ _________________
SEMINAR _________________ _________________
VACATION OR PTO _________________ _________________
OTHER _____________________ _________________ _________________
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