Request For Leave Of Absence
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1REQUEST FOR LEAVE OF ABSENCE
Date Requested__________
Employee Name: ____________________ Employee ID Number: ________________
Program Name: ___________________
REQUEST FOR LEAVE
To Begin on _____________ at ______AM_____PM on: ________________20___
(Day)
(Time)
(Date)
To End on _____________ at ______AM_____PM on: ________________20___
(Day)
(Time)
(Date)
LEAVE TO BE CHARGED AS FOLLOWS:
Annual Leave _______Hours
Military Leave
_____Hours
Sick Leave
_______Hours
Compensatory Leave _____Hours
(Personal)
Sick Leave
_______Hours
Leave without pay
_____Hours
(Accident on Duty)
Funeral Leave
_____Hours
Other (explain)
_____Hours
REMARKS/REASON_______________________________________________
Employee Signature______________________________ Date: _______________
Approved
Disapproved
Signed by: _________________________
Date: ____________, 20___
Immediate Supervisor
Signed by: __________________________
Date: ____________, 20___
Program/Department Head
Signed by: __________________________
Date: ____________, 20___
Director of Children & Families
Signed by: ___________________________
Date: ____________, 20___
President/CEO
**Annual Leave Request must be requested in writing at least 24 hours in advance to the
immediate supervisor.
**Annual Leave Requests may be denied or approved at the discretion of the immediate
supervisor depending on the needs of the work site.
**Employees must bring a certificate of illness signed by a physician for sick leave of more than
(3) days.
**Employees knowing of a Doctor’s appointment should submit “Sick Leave” form ahead of
time.
Revised September 2011 approved by President/CEO
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Parent category: Business