Fill and Sign the 40 Effective Time off Request Forms Ampampamp Templates

Leave and Vacation Request Form Page 1 of 3Basic form © James R. McDade (ver: 12-03-01) 209-667-2300 LEAVE AND VACATION REQUEST FORM Note: Employers use this form to track the requests for leave. This form should be modified to delete those leaves and information that do not apply and to add any other leaves that are particular to the company. (Delete this note prior to use.)Employee Name: ____________________________________ Date: _____________TYPE OF LEAVE REQUESTEDThe employee should mark the leaves requested and mark or complete the applicable blanks.____Vacation (At company’s option.)____Paid Sick Leave (At company’s option.) ____Illness of employee____ Illness of employee’s family member (specify who: ____________)____ Doctor’s or dental appointment of employee____ Doctor’s or dental appointment for family member (specify who: ____________)The employee must also submit a doctor’s note if the employee’s (or family member’s) illness is longer than [3] days. ____ Unpaid Medical Leave (At company’s option.) The employee must also submit a doctor’s note if an illness is involved. ____ Unpaid Personal Leave (At company’s option.) State the general reason the leave is needed without revealing confidential medical information: ___________________________________________________________The employee must also submit a doctor’s note if an illness is involved. ____ Family Care Leave (FMLA/CFRA) (Applies if company has 50 or more employees.) A separate FMLA/CFRA leave request and notice form must also be completed.The employee must also submit a doctor’s note if an illness is involved. ____ Pregnancy Disability Leave (PDL) (Applies if company has 5 or more employees.) A separate PDL leave request and notice form must also be completed.The employee must also submit a doctor’s note. ____Workers’ Compensation Leave (Applies to all companies.) An IIPP accident / illness report must also be completed.The employee must also submit a doctor’s note. ____Bereavement (Funeral) Leave (At company’s option.) Employee may be requested to provide proof of death. ____ Jury Duty, Witness, or Domestic Violence Leave (Applies to all companies.) The employee must also submit the court summons. ____ Alcohol or Drug Rehab Leave (Applies if company has 25 or more employees.) The employee may be required to provide proof of attendance. ____ Military Leave (Applies to all companies.) The employee may be required to provide proof of order from commanding officer. Leave and Vacation Request Form Page 2 of 3Basic form © James R. McDade (ver: 12-03-01) 209-667-2300____Request to Attend Child's School Due to Suspension (Applies to all companies.) The employee may be required to provide proof of attendance. ____ Child's School Activity Leave (Applies if company has 25 or more employees.) The employee may be required to provide proof of attendance. ____ Other: _________________________________________________DURATION OF REQUESTED LEAVE1.The employee requests that the _______________________________ leave begin on ___________, 20__ at ___ __.M. and end on ___________, 20__ at __ __.M.2. The employee requests that the _______________________________ leave begin on ___________, 20__ at ___ __.M. and end on ___________, 20__ at __ __.M.__________________________________________ _________________________Employee’s Signature Date  THIS RESPONSE PORTION TO BE COMPLETED BY HR DEPARTMENT  LEAVE ASSESSMENT1.At the time of the leave is to begin, the employee will have ______ days / hours of the requested ___________________ leave available.2. The employee has met all eligibility requirements to be granted the leave? (___ Yes) (___ No) Remarks, if needed: ___________________________________________.3.Required doctor’s notes or supporting documentation are attached or are expected? (___ Yes) (___ No) Remarks, if needed: ____________________________________.4.The employee’s supervisors have been notified of the leave and work assignments are covered? (___ Yes) (___ No) Remarks, if needed: __________________________.5. While on the above-requested leave, the employee should also be taking the following leave simultaneously (i.e., FMLA and WC should run concurrently): _______________ ____________________________________________________________________.APROVAL OF LEAVE___ Please see the FMLA/CFRA Request and Notice for details.___ Please see the PDL Request and Notice for details.____ The employee’s leave has been approved as requested above. The employee is to report back to work on _______________, 2000 at ____ A.M. / P.M. Time will be deducted from the employee’s allotment of leave as follows: ____ days / hours from ____________ leave; and ____ days / hours from ____________ leave. Leave and Vacation Request Form Page 3 of 3Basic form © James R. McDade (ver: 12-03-01) 209-667-2300____The employee’s requested leave has been partially granted as follows: ___The requested ______________ leave will only be granted from [date] to [date].___ The employee is granted a _______________ leave from [date] to [date] instead of the requested _______________ leave.___After the _______________ leave expires, the employee will then be on _______________ leave from [date] to [date].___ While on _______________ leave from [date] to [date], the employee will also be on _______________ leave.___Other: _______________________________________________________. DENIAL OF LEAVE____ The requested leave is denied because: ___________________________________.ADDITIONAL INFORMATION FOR EMPLOYEEUnless a leave is required by the government to be provided, job reinstatement is not guaranteed. [OPTION>However, if a leave is granted and the employee is ready to return to work on or before the expected return date indicated above, then the Company will make an effort to reinstate the employee to his or her previous position or to a substantially similar position unless the Company, for business reasons, is unable to hold the position open and no substantially similar position exists at the time the employee is expected to return to work.The employee should review the employee handbook to be reminded of the rules for taking and returning from a leave of absence, the affect a leave may have on benefits, and the Company’s rule prohibiting gainful employment during a leave of absence unless prior authorization is received.Nothing in this form is intended to alter the at-will employment relationship of the parties. Either party may terminate the employment relationship at any time with or without prior cause or notice.If the employee has any questions, or if circumstances surrounding the requested leave change, the employee should call __________________ at (____) _____-_________.Sincerely,_____________________________Company RepresentativeI hereby acknowledge receipt of the completed response portion of this “Leave and Vacation Request Form”. If I find information in this form that I believe is not correct, then I will contact the above company representative immediately.____________________________________ Date: ________________Employee’s Signature[NOTE TO EMPLOYER: If the employee is not present to sign for a copy of this notice, send the notice via certified mail.]