Can the form be signed electronically?

Yes. Electronic signatures are legally valid for most employment forms under the ESIGN Act (15 U.S.C. ch. 96, 2000) and UETA where adopted. Ensure the platform captures intent, consent, attribution, and retention capabilities to satisfy the legal validity test.

How should medical information be protected?

Limit access to HR and benefits staff and store records on secure systems. For healthcare-related PHI, follow HIPAA safeguards and maintain a Business Associate Agreement when a vendor handles protected health information.

Who reviews and approves intermittent leave?

The employee initiates the request, the manager confirms operational impact, and HR reviews eligibility, requests certification if needed, and records the approved schedule in payroll and HRIS.

What if the employee misses required certification deadlines?

Employers may follow written policy to request timely certification; failure to provide documentation can affect approval or pay treatment, but employers should apply policies consistently and consider extensions for extenuating circumstances.

Is notarization ever required?

Notarization is not typically required for intermittent leave forms. Check state or employer-specific rules if a form includes sworn statements or power-of-attorney elements that may require notarization.

How long must these records be retained?

Retention follows federal and industry rules: retain payroll/benefit records at least 3 years under IRC §6501(a) and retain HIPAA-related records 6 years under 45 CFR §164.530(j); state laws may require longer periods.

Electronic Signature
Templates
HR
Employee Intermittent Leave Form

Employee Intermittent Leave Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

EMPLOYEE INTERMITTENT LEAVE FORM

Personal Information

Employee Name:

Home Address Phone Email

Position Information

Job Title Department Reporting Manager

Employee Start Date:

Current Compensation

Leave Request Details

Type of leave requested: FMLA-qualifying Medical leave (non-FMLA) Family care Other

If Other, specify

Anticipated effective date of leave:

Requested intermittent pattern (check all that apply): Daily (hours) Weekly (days) Monthly (episodes)

If daily, approximate hours per occurrence If weekly/monthly, describe expected frequency

Medical/Reason for Leave

Primary reason for intermittent leave Attending Health Care Provider (if applicable) Provider phone

Medical certification will be required to support intermittent leave requests. By signing below you authorize release of necessary medical information to verify eligibility and anticipated pattern of leave.

Employer-Provided Scheduling and Substitution

The employer may require a reasonable schedule of intermittent leave occurrences when practicable. The employer may require substitution of accrued paid leave for periods of unpaid intermittent leave consistent with policy. Employee must provide notice as soon as practicable of need for leave and fit scheduling into departmental needs when possible.

Employee elect to substitute accrued paid leave for unpaid intermittent leave: Yes No

Employment History (most recent)

Employer 1 - Company Name Employer 1 - Job Title

Dates Employed: From To

Employer 1 - Responsibilities / Reason for Leaving Employer 2 - Company Name Employer 2 - Job Title

Dates Employed: From To

Employer 2 - Responsibilities / Reason for Leaving

Education

Highest Degree Institution

Graduation Date:

References (Professional)

Reference 1 - Name Reference 1 - Phone Reference 1 - Relationship Reference 2 - Name Reference 2 - Phone Reference 2 - Relationship Reference 3 - Name Reference 3 - Phone Reference 3 - Relationship

Legal Disclosures and Authorizations

At-Will Employment: Nothing in this form modifies the employment relationship. Employment remains at-will and may be terminated by either the employee or the employer in accordance with company policy and applicable law.

Equal Opportunity: The employer provides equal employment opportunity and will administer leave requests without unlawful discrimination. The employer will evaluate reasonable accommodations and leave consistent with applicable law.

Authorization to Contact and Background Checks: By signing this form, the employee authorizes the employer to contact listed previous employers and references for purposes related to verifying employment history and the leave request. The employer may conduct background or verification checks as permitted by law to the extent those checks are relevant to the leave request.

Employee Certification and Release

I certify that all information provided on this form is true, complete, and correct to the best of my knowledge. I understand that knowingly providing false information may result in disciplinary action, up to and including termination. I authorize release of medical information to the employer's designated representative for purposes of evaluating and administering this intermittent leave request. I understand that medical information will be treated confidentially in accordance with applicable law.

I understand and agree to the following (initials required)

HR Use Only

Leave balance (hours)

HR determination: Approved Denied Pending further certification

HR Reviewer (Printed Name) HR Comments

Employee Signature

Employee Printed Name:

Signature:

Date:

What the Employee Intermittent Leave Form Is

The Employee Intermittent Leave Form documents requests for non-continuous leave periods where an employee needs time away in separate blocks instead of a single continuous absence. It captures employee details, the medical or qualifying reason, anticipated frequency and duration of absences, and employer instructions for certification and return-to-work. Employers use the form to track intermittent absences for payroll, benefits, workplace accommodations, and compliance with federal and state leave laws such as the Family and Medical Leave Act (FMLA) and state paid-leave statutes.

Why a Structured Intermittent Leave Form Matters

A consistent form reduces disputes, clarifies expectations, and supports compliant case management. It helps employers document medical certification, leave scheduling, and intermittent leave approvals while preserving a clear audit trail for payroll and benefits.

Who Typically Completes and Reviews This Form

Human resources and managers use the form to document intermittent leave requests and decisions before routing to payroll or benefits.

HR managers and benefits administrators responsible for FMLA and state leave coordination.
Supervisors and department managers approving intermittent schedules and staffing adjustments.
Employees requesting intermittent time off and medical providers supplying certification.

Employees complete the initial request and, when required, medical providers submit certification; third-party administrators may also manage the workflow.

Key Roles and Authorities

HR Manager

HR Managers review requests, request medical certification when permitted, record approvals or denials, and ensure the form is retained according to records-retention rules and company policy.

Employee

Employees complete and sign the form, provide accurate contact and scheduling details, and supply required supporting documentation such as provider certification within employer timeframes.

Essential Fields to Collect

Employee Name: Full legal name

Employee ID: Company identifier

Leave Type: FMLA, sick, ADA

Intermittent Pattern: Frequency and duration

Provider Contact: Clinic or physician

Certification Date: MM/DD/YYYY

Consequences of Incorrect or Missing Information

FMLA Noncompliance: Leave designation errors

Payroll Mistakes: Incorrect pay or deductions

Privacy Breach: Unauthorized PHI disclosure

Discrimination Risk: Failure to accommodate

Benefit Disruption: Coverage or eligibility gaps

Recordkeeping Penalty: Regulatory citation risk

Common Errors to Avoid When Preparing the Form

Incomplete provider certifications or missing signature blocks that delay review and create ambiguity about authorized dates.
Vague intermittent schedules such as 'a few days each month' instead of specifying expected frequency and typical duration.
Mismatched employee identity details (name or ID), which complicate payroll and benefits reconciliation.
Failing to redact or limit protected health information when sharing forms beyond HR and payroll, increasing privacy risk.

How to Complete the Employee Intermittent Leave Form

Follow a consistent sequence to ensure the form is complete, authorized, and routed to payroll and benefits without delay.

01

Complete Employee Section: Enter name, ID, department, and contact details.
02

Describe Intermittent Need: Specify reason, expected frequency, and typical duration.
03

Attach Certification: Include provider statement and signature if required.
04

Route for Approval: Send to manager, HR, and payroll for processing.

How to Configure the Form in an Online Workflow

Key settings align the form to your HR systems and ensure required fields and routing are enforced.

Template Name	Employee Intermittent Leave Form template
Required Fields	Employee name, ID, schedule, provider signature
Signer Roles	Employee \| Manager \| HR reviewer
Authentication	Email link or SMS code for signer identity
Notifications	Auto-reminders: 3 and 7 days before review

Digital Signing and Integration Considerations

Ensure your e-signature platform supports secure authentication, audit trails, and integration with HRIS and payroll systems.

Authentication Options: Email, SMS, KBA
Integrations: Salesforce, NetSuite, Microsoft 365
File Formats: PDF, DOCX supported

Choose settings that preserve an audit trail, enable secure storage, and allow export to payroll and personnel records without exposing unnecessary PHI.

Where to Send Completed Forms

After completion, route the form to the correct handlers to update leave records and payroll without delay.

HRIS Upload: Store in employee file within HR information system.
Payroll Team: Submit for pay adjustments and timekeeping.
Manager: Inform about approved intermittent schedule.
Benefits Administrator: Update benefits eligibility and coverage dates.

Typical Timelines and Processing Expectations

Establish clear internal deadlines to avoid delays; common practice uses short windows for both submission and review.

Employee Notice:

Submit request as soon as practicable; ideally before first intermittent absence.

Provider Certification Deadline:

Provide documentation within 15 calendar days when reasonably possible.

Employer Acknowledgement:

Acknowledge receipt within 3–5 business days of submission.

Payroll Update:

Process within the next payroll cycle after approval.

Recertification Frequency:

Request recertification only as permitted under policy or law.

Practical Examples of Use

Two concise scenarios show how the form supports consistent, auditable leave handling across different organizations.

Mid-size Manufacturer

A production supervisor receives intermittent leave requests from a machinist with a chronic condition

HR requests provider certification within 15 days
The company documents approved half-day absences, updates timekeeping, and preserves records for three years to support audits and benefits reconciliation.

Community Health Clinic

A nurse requests intermittent leave for ongoing treatment

Clinic collects signed provider certification and a HIPAA authorization
HR restricts access to PHI, coordinates temporary coverage, and retains records for six years to comply with HIPAA retention rules.

Comparing eSignature Options for Intermittent Leave Workflows

Price and capability vary by vendor; signNow appears first for easy reference and to show common pricing and compliance differences.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies	Varies	Varies	Varies
Bulk Send	Yes	Yes	Yes	Yes	Varies
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently Asked Questions

Answers to common questions about completing, submitting, and protecting Employee Intermittent Leave Forms.

Need help? Contact support

Can the form be signed electronically?
Yes. Electronic signatures are legally valid for most employment forms under the ESIGN Act (15 U.S.C. ch. 96, 2000) and UETA where adopted. Ensure the platform captures intent, consent, attribution, and retention capabilities to satisfy the legal validity test.
How should medical information be protected?
Limit access to HR and benefits staff and store records on secure systems. For healthcare-related PHI, follow HIPAA safeguards and maintain a Business Associate Agreement when a vendor handles protected health information.
Who reviews and approves intermittent leave?
The employee initiates the request, the manager confirms operational impact, and HR reviews eligibility, requests certification if needed, and records the approved schedule in payroll and HRIS.
What if the employee misses required certification deadlines?
Employers may follow written policy to request timely certification; failure to provide documentation can affect approval or pay treatment, but employers should apply policies consistently and consider extensions for extenuating circumstances.
Is notarization ever required?
Notarization is not typically required for intermittent leave forms. Check state or employer-specific rules if a form includes sworn statements or power-of-attorney elements that may require notarization.
How long must these records be retained?
Retention follows federal and industry rules: retain payroll/benefit records at least 3 years under IRC §6501(a) and retain HIPAA-related records 6 years under 45 CFR §164.530(j); state laws may require longer periods.

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