Leave Form Template
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Complete Leave Form Template with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
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1Leave Form
Employee Name: ________________________ Department __________________________
TO BE COMPLETED BY EMPLOYEE:
Type of leave requested:
Ο
Annual Leave
(12 month employees only)
Ο
Personal Leave
(9-11 month employees only)
Ο
Sick Leave
(For absences of 3 or more consecutive days, a physician’s release to return to work is
required)
Ο
Workers’ Compensation Leave
(Is this absence due to work related illness or injury? If yes, have you forwarded an Incident Report to HR? If
no, please attach the Incident Report)
Ο
Administrative Leave
(Event documentation must be attached)
Ο
Bereavement
(3 days for immediate family; documentation must be attached)
Ο
Leave Without Pay
(For unpaid leave, please briefly state reason)
Comments: _________________________________________________________________
DATES INVOLVED:
(Only enter actual dates of absenteeism)
Date: ________________________ Number of Hours: ______________________
Date: ________________________ Number of Hours: ______________________
Date: ________________________ Number of Hours: ______________________
Date: ________________________ Number of Hours: ______________________
Date: ________________________ Number of Hours: ______________________
Date: ________________________ Number of Hours: ______________________
Date: ________________________ Number of Hours: ______________________
Date: ________________________ Number of Hours: ______________________
Date: ________________________ Number of Hours: ______________________
Date: ________________________ Number of Hours: ______________________
Total number of hours: _____________ Total number of days: _______________
I understand that if I have no leave on the books, my wages may be adjusted accordingly.
Employee Signature: ____________________________ Date: ________________________
: __________________
________
Supervisor/Manager Signature
Approved ____ Denied ___ Date:
Department Head Signature: ______________________ Date: ________________________
DO NOT WRITE BELOW THIS LINE. FOR HR USE ONLY
Entered by: _______________________________ Date: _____________________________
Revised 03/27/12
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Parent category: Business