Leave Request Form
KIQ-HR-003
Date of request:
*
/
Day
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Month
Year
Personal Information
Name
*
First Name
Last Name
Email
*
Phone Number
*
Leave Type
Select leave type/s:
*
Annual Leave
Personal Leave - Sick
Personal Leave - Carers
Leave Without Pay
Long Service Leave
Other
If you selected 'Other' above, please add the leave type/s here:
Leave Information
Leave requested from:
*
/
Day
/
Month
Year
Date
Leave requested to:
*
/
Day
/
Month
Year
Date
Number of work days:
*
First date back at work:
*
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Day
/
Month
Year
Date
Other Information:
Personal Leave - Sick and Carers
If you have been on personal leave for 2 or more days, you will need to provide a medical certificate or statutory declaration to be paid for this leave.
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If you are sick onsite, have you notified the Client Representative?
*
Please Select
Yes
No
Not Applicable
If you are sick onsite, have you notified your Kinetiq Solutions Supervisor?
*
Please Select
Yes
No
Not Applicable
If you are sick onsite, have you notified the medic?
*
Please Select
Yes
No
Not Applicable
Signature
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