Leave Request Form

Date of Request

Date

Employee Name

Employee Email

example@example.com

Supervisor Email

example@example.com

Supervisor Email

Jobsite

Description of requested time off reason.

Vacation / Sick Leave:
Start Date: Date - End Date: Date

Total Vacation / Sick Hours

Bereavement Leave:
Start Date: Date - End Date: Date

Total Bereavement Hours

Jury Duty Leave:
Start Date: Date - End Date: Date

Total Jury Duty Hours

Other (e.g., sabbatical leave, school visitation, etc.):
Start Date: Date - End Date: Date

Total Other Hours

Will you be using PTO (Please refer to your paycheck for PTO available)

If yes how many hours of PTO do you want to use

Employee Signature