Leave of Absence Request Form

This form is used by employees to formally request a leave of absence from work for personal, medical, or other approved reasons. Completing this form ensures documentation and appropriate coordination with Human Resources and management.

Employee Information

Full Name: {fullName}

Employee ID: {employeeId}

Department: {department}

Job Title: {jobTitle}

Supervisor Name: {supervisorName}

Date of Request: {requestDate}

Leave Details

Type of Leave Requested: {leaveType}

Start Date: {startDate}

End Date: {endDate}

Total Number of Days: {numberOfDays}

Is this related to a medical condition?

{#isMedical}

Name of Treating Physician: {physicianName}

Medical Certification Provided: {medicalCertification}

{/isMedical}

Reason for Leave

{leaveReason}

Contact Information During Leave

Email: {contactEmail}

Phone: {contactPhone}

Address During Leave: {contactAddress}

Approval Workflow

Additional Notes

{additionalNotes}

Employee Signature: ______________________

Date: ______________________

HR Use Only:

• Received By: {receivedBy}
• Date Received: {receivedDate}
• HR Comments: {hrComments}