Human resources
Leave request template (US)
A general template under US law. Laws differ from state to state, so check it against your state's law or with a lawyer licensed there. We are not a law firm and do not give legal advice.
Fill in this template- Written for US law, with your state left to fill in
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Preview — US standard
Leave Request
To: Manager Name, Manager Title
From: Employee Name, Job Title, Employee ID Employee ID
Department: Department
Date of request: Request Date
Leave Requested
• Type of leave: Leave Type, such as Vacation, Personal, Sick, Family and Medical Leave, Jury Duty, Military or Unpaid
• First day of leave: First Day of Leave
• Last day of leave: Last Day of Leave
• Return to work: Return Date
• Total: Number of Days or Hours
• Paid time off to be used: Hours of PTO to Use, or None
Reason (optional)
Reason for Leave, if You Choose to Share It
If this leave may be for a serious health condition, the birth or placement of a child, military family needs, or another reason protected by the Family and Medical Leave Act or state law, Human Resources will give me the required notices and any certification forms. I understand I do not need to share medical details with my manager.
Coverage
While I am away, Coworker Name will cover: Duties to Be Covered. I can be reached for urgent matters at Contact Details, or Not Available.
Employee signature: Employee Signature
Date: Employee Signing Date
Manager Decision
Approved / Approved with Changes / Not Approved
Comments: Manager Comments
Manager signature: Manager Signature
Date: Manager Signing Date