Medical Leave Request Form

Purpose: This form is used by employees to formally request medical leave due to illness, injury, or any health-related condition that prevents them from performing their professional duties.

Employee Details

Full Name: {fullName}

Employee ID: {employeeId}

Department: {department}

Job Title: {jobTitle}

Supervisor Name: {supervisorName}

Date of Request: {requestDate}

Medical Leave Information

Type of Leave: {leaveType}

Reason for Leave: {reason}

Leave Start Date: {startDate}

Expected Return Date: {returnDate}

Contact During Leave

Phone Number: {contactPhone}

Email Address: {contactEmail}

Medical Documentation

{#hasMedicalCertificate}Employee has provided medical certification.{/hasMedicalCertificate}

{^hasMedicalCertificate}No medical certification has been provided.{/hasMedicalCertificate}

Additional Comments

{additionalComments}

Approvals

Checklist

{#requirements}

• {item}

{/requirements}

Please ensure all information is accurate and complete to avoid delay in leave approval.