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Leave of absence request form template

A Leave of Absence Request Form is a document that an employee submits to request time off from work for a specific period of time. The form typically includes information such as the employee's name, job title, department, reason for the leave, duration of the leave, and any relevant supporting documentation.

The purpose of a leave of absence request form is to provide a standardized way for employees to request time off for various reasons, such as personal or family obligations, medical issues, military service, or professional development.

The form helps employers track and manage employee absences, ensuring that they are aware of who will be away from work and for how long. It also provides a clear and consistent process for employees to follow when requesting time off, helping to minimize confusion and misunderstandings.

A typical leave of absence request form may include the following sections:

  1. Employee information: This section includes the employee’s name, job title, department, and contact information.
  2. Type of leave: This section specifies the type of leave being requested, such as annual leave, sick leave, family and medical leave, or military leave.
  3. Duration of leave: This section indicates the start and end dates of the leave, as well as the total number of days or weeks requested.
  4. Reason for leave: This section provides a brief description of the reason for the leave, including any relevant details or supporting documentation.
  5. Return date: This section specifies the date the employee plans to return to work, if applicable.
  6. Supervisor’s approval: This section includes space for the supervisor’s signature and date, indicating approval of the leave request.
  7. Additional information: This section allows employees to provide any additional information or comments related to their leave request.
  8. Signature and date: This section includes space for the employee’s signature and date, confirming that they have reviewed and agree to the terms of the leave request.

Once the form is completed, it is typically submitted to the employee’s supervisor or human resources representative for review and approval.

Leave of absence request form template

Employee Information:

Name: [Insert name here]
Job Title: [Insert job title here]
Department: [Insert department here]
Hire Date: [Insert hire date here]
Work Location: [Insert work location here]

Type of leave:

Military Leave (must provide verification from appropriate military authority)
Military Service

Personal Leave (up to 30 days, unpaid)
Reason: [Insert reason here]

Non-FMLA Medical Leave

Start of leave (first day absent from work): [Insert start date here]

End of leave (last day absent from work): [Insert end date here]

Regular hours worked per week: [Insert number of hours here]

Full-time or Part-time: [Insert full-time or part-time here]

Intermittent Leave Request: [Yes or No]

If yes, please attach proposed schedule.

Leave details:

Number of days of leave requested: [Insert number of days here]
Dates of leave: [Insert dates of leave here]
Reason for leave (if personal or medical): [Insert reason here]

Approval process:

Supervisor Approval: [Insert supervisor signature block here]
HR Approval: [Insert HR signature block here]


  • All requests for non-FMLA leaves of absence must be submitted to HR for approval.
  • Employees are required to provide supporting documentation for any medical leave request.
  • Any changes to the original leave request must be submitted in writing to HR for approval.
  • During the leave, the employee will remain employed by the university but will not receive pay or benefits.
  • Upon return from leave, the employee will be reinstated to their previous position or a similar position, if available.

Disclaimer: This policy template is meant to provide general guidelines and should be used as a reference. It may not take into account all relevant local, state or federal laws and is not a legal document. Neither the author nor Workable will assume any legal liability that may arise from the use of this policy.

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