Annual Leave Request Form
This form is to record request for annual leave and is to be completed by individual colleagues and submitted. It must be completed at least one month before annual leave is requested. Annual Leave years runs from January to December.
Date of Request
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Colleague Full Name:
*
First Name
Last Name
First Date of Proposed Annual Leave
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Last Date of Proposed Annual Leave
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Total Number of Hours
*
Declaration 1
*
I declare the above information is correct and I understand that my request for annual leave is not authorised until it has been countersigned by the office.
Declaration 2
*
I accept that if I take any leave without the prior authorisation, it will be viewed as unauthorised absence.
Signature of Employee
*
Submit
To be completed by Office
Annual Leave Authorised
Please Select
Yes
No
Annual Leave Authorised By
First Name
Last Name
Designation
Please Select
Registered Manager
Care Services Manager
Head of Nursing/Lead Nurse
Sister/Charge Nurse
Date Annual Leave Authorised
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Should be Empty: