Human resources
Short leave (permission) 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.
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Preview — US standard
Time Off Request (Partial Day)
To: Manager Name, Manager Title
From: Employee Name, Job Title, Department
Date: Request Date
I am requesting time off on Date of Time Off, from Start Time to End Time, for a total of Total Hours hours.
Reason: Reason, such as a medical appointment, family matter or personal errand
I would like to use: Paid Sick Time, Paid Time Off, Unpaid Time or Make-Up Time Where Allowed
If this time is for my own or a family member's health, it may qualify as protected paid sick leave under state or local law, and I understand I am not required to give more detail than the law allows.
Coverage while I am away: Coverage Arrangements
Employee Signature
Employee Printed Name
Decision
Decision: Approved or Not Approved
Leave type recorded: Leave Type Recorded
Approved by: Approver Name and Signature Date: Decision Date