Employee Leave Request

EMPLOYEE REQUEST/REPORT FOR TIME OFF

*required fields

Staff Member Name*

First Last

Staff Member Email*

Supervisor's Name*

First Last

Supervisor's Email*

Absent

I was absent from work on the following days:

List absent date range
List each absent date separate
None

From*

Thru*

Hours each day*

Absent Date*

Absent total hours*

Second absent date?

Yes

Second absent date*

Second absent total hours*

Third absent date?

Yes

Third absent date*

Third absent total hours*

Fourth absent date?

Yes

Fourth absent date*

Fourth absent total hours*

Fifth absent date?

Yes

Fifth absent date*

Fifth absent total hours*

Time Off

I would like to request time off work:

List time off date range
List each time off date separate
None

From*

Thru*

from time*

:

to time each day*

:

Time off date*

Time off total hours

from*

:

to*

:

Second time off date?

Yes

Second time off date*

Second time off total hours

from*

:

to*

:

Third time off date?

Yes

Third time off date*

Third time off total hours

from*

:

to*

:

Fourth time off date?

Yes

Fourth time off date*

Fourth time off total hours

from*

:

to*

:

Fifth time off date?

Yes

Fifth time off date*

Fifth time off total hours

from*

:

to*

:

Deduct these hours from

SICK (Total Hours)

VACATION (Total Hours)

PERSONAL (Total Hours)

WITHOUT PAY (Total Hours)

Family Medical leave act

Starting

Anticipated ending

Job responsibilities

If this is a request for time off in the future, please list below your job responsibilities during the time you will be off and who will be covering them for you. Please check your calendar for that time frame for all activities/appointments that may need adjusting.

Job 1

Job 2

Job 3

Job 4

SIGNED

Typing your initials here is your signature*

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Employee Leave Request

Absent

Time Off

Deduct these hours from

Family Medical leave act

Job responsibilities

SIGNED

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