Establishing secure connection…Loading editor…Preparing document…

Personal Discretionary Leave Request Form

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

Personal/Discretionary Leave Request Form

(Do not use this form to apply for FMLA, OFLA or Sabbatical Leaves)

Employee Information

PSU ID Number

Last Name

First Name

Middle Name

Street/PO Box

New?

City

State

Zip Code

Primary Phone Number

Home Phone Number

Email Address

New?

Employee Classification

Leave Starting and Return-to-Work Dates

(only apply for absences exceeding five workdays)

I request leave from official duty beginning on:

Date

Time

I expect to return to work on:

(You must provide doctor’s release at the end of a medical leave.)

Date

Time

Reason(s) For Personal Leave

(check all that apply)

Your FMLA/OFLA is exhausted OR you do not meet FMLA/OFLA requirements. (If applicable, please forward a completed Physician’s Certification to HR.)

Your vacation has been exhausted and you are requesting time off for non-medical reasons.

You are an academic employee requesting time off for personal or professional reasons, not a sabbatical. Check with your department and the Office of Academic Affairs regarding your tenure clock.

You are requesting a Search and Rescue leave provided under the SEIU bargaining agreement. (Please attach appropriate documentation.)

You are requesting Military Leave or time off to serve in the Peace Corps. (Please attach a copy of your military orders or your Peace Corps assignment papers).

Other reasons. (Please describe and attach appropriate documentation as applicable.)

Use of Accruals to Continue Pay Before Unpaid Status

(check all that apply)

If eligible for use, I acknowledge I must use all my available paid sick leave before beginning leave without pay. (For medical leaves only)

Classified Employees Only: If available, please use all compensatory leave time or exchange leave time before beginning leave without pay.

I have used all my available paid leave balances and understand the entire leave will be without pay.

Classified Employee Only: I want to retain up to 40 hours vacation leave. (If hours are retained then hardship donations cannot be requested.)

If eligible for use, use all my available vacation leave before beginning leave without pay.

Classified Employees Only: I will apply for Hardship Leave and forward it to HR for approval. I understand I have to use all my available paid leave balances and then have a doctor’s certification that I will be out for at least 30 more days after my leave accruals are gone.

Unclassified Employees Only: I want to use my vacation intermittently to meet the 80 hour rule and continue benefits, if possible.

Other pay requests (please specify):

Classified Employees Only: If available, please use all personal leave time before beginning leave without pay.

Additional Leave Details

Are you requesting an intermittent leave? Yes No

Do you want to work less hours per day or less days per week than your normal schedule? (please describe below):

Benefits While on Personal Leave Without Pay

Mandatory Benefits:

Generally an employee who receives less than 80 hours of pay during a prior month will not be covered for mandatory benefits. A COBRA notice will be sent to your home address on record and you may elect to pay the premiums to continue your benefits. Note: the University is not allowed to pay for COBRA through any grant or regular funding.

Optional Benefits:

If you wish to continue to pay for your optional benefits while on leave without pay, you need to make an appointment to meet with a Benefits representative in Human Resources to discuss how to pay for those benefits that are eligible for continuation.

Check here if you want someone from Benefits to contact you.

Your Phone Number

Your Email Address

Employee Signature

I understand that I am not guaranteed a return to my current position unless required by my Collective Bargaining Agreement, state and/or federal law, and/or the Administrative Rules for the State of Oregon.

Signature

Date

Approvals

Department: Return a signed copy to employee; keep a copy for your records. Original form goes to the Leaves Manager in the Office of Human Resources for payroll and record keeping requirements. HR approval is subject to receipt of all applicable documentation, including such forms as the Medical Certification, military orders, etc.

Department Chair/ Manager Approval

Date

Department

Department Chair/ Manager Printed Name

Phone Number

Manager’s Email Address

Dean/ Director Approval

Date

Department

Provost/ Vice President Signature

Date

Department

HR/Benefits Approval

Date

Department

Human Resources Use Only

Instructions for Completing Personal/Discretionary Leave Request Form

Complete this form before leave is taken to ensure it is approved. In the event of an unplanned absence, you will be asked to complete the form as soon as possible.

Medical Leave to Care for Yourself or a Family Member

If you do not qualify for protections under the Federal Family Medical Leave Act (FMLA) or the Oregon Family Leave Act (OFLA) as outlined below, you may apply for leave for medical reasons using the Personal/Discretionary Leave Request. When submitting the request, attach a Physician’s Certificate confirming inability to work for you or your family member. The University reserves the right to request updated medical information during the leave. Complete the Personal/Discretionary Leave Request Form at least 30 days prior to leave to ensure it is approved. In the event of a medical emergency or other unforeseeable event, you must complete the form as soon as possible. This leave is not intended to cover minor conditions for which treatment and recovery are very brief (less than two treatments).

If your reason for being on leave is covered by the Federal Family Medical Leave Act (FMLA) or the Oregon Family Leave Act (OFLA) and you think you are eligible for these leaves, please refer to the website at http://www.pdx.edu/hr for more information. Find out how to apply for these leaves that protect your job. Please note: If you are eligible for FMLA, your mandatory benefits will continue to be covered during the approved absence.

FMLA eligibility

• You must have at least 12 months of employment (need not be consecutive service time); AND

• During your last 12 months of employment prior to the leave request, you must have worked or been paid for at least 1,250 hours.

OFLA eligibility

• You must have at least 180 calendar days of employment prior to the leave request; AND

• Worked an average of 25 hours or more per week during that period unless requesting “parental leave.”

Other Leave Reasons

Attach required documentation such as orders to report to military duty, assignments papers for Peace Corps, subpoena and/or notice of jury selection, or other appropriate documentation from a proper authority. Complete the Leave Request Form at least 30 days prior to leave to ensure it is approved. In the event of a medical emergency or other unforeseeable event, you must complete the form as soon as possible.

Are you requesting an intermittent or reduced hour schedule?

If yes, you must attempt to schedule leave to be least disruptive to the operations of the department.

Returning to Work

At the end of the leave if it is for medical reasons, please provide a note from your doctor that states you have been released to return to work. Provide a copy to your supervisor/manager and the Office of Human Resources. Employees who are on military leave from PSU (veterans and reservists) and returning from active duty must notify PSU of their intention to resume their former job within 90 days of release from duty. Reservists and guardsmen returning from training must only inform PSU of the training obligations and report back at the “next regularly” scheduled working period.

Enter text✕
Prepare your document for signing right on this page
  • 01 Edit the text and complete the fields
  • 02 Click Sign Now and on the next screen add recipients and signature fields in SignNow
  • 03 Start your free trial to sign and send your doc
Sign Now

What the Personal Discretionary Leave Request Form Is

The Personal Discretionary Leave Request Form is an HR document employees submit to request short-term time away from work for non-medical, personal reasons. It records employee identity, leave dates, reason category, manager approval, and any agreed pay or benefits treatment. Employers use the form to document discretionary approvals, track attendance impact, and integrate with payroll and scheduling systems. The form can be a paper form or an electronic fillable document and may be signed electronically under federal and state e-signature laws when permitted.

Why a Clear Leave Request Form Matters

A professional Personal Discretionary Leave Request Form standardizes requests, reduces administrative back-and-forth, preserves audit-ready records, and ensures consistent treatment across employees. Clear fields speed approvals and reduce payroll errors while supporting compliance with recordkeeping obligations under federal and state employment law.

Why a Clear Leave Request Form Matters

Who Typically Completes and Reviews This Form

Multiple stakeholders should retain copies: employee, manager, and HR, each recorded in the HRIS or personnel file.

  • Employees requesting short-term, non-medical leave or schedule adjustments.
  • Direct managers who review operational impact and approve or deny requests.
  • Human Resources for recordkeeping, payroll coordination, and policy compliance.

Essential Elements of a Professional Leave Request Form

A well-designed form combines clear fields, decision metadata, and routing fields so it functions as both employee request and an audit record for HR and payroll systems.

Employee Details

Full legal name, employee ID, department and contact details to match payroll and personnel records accurately.

Leave Type

A selectable field (discretionary, bereavement, jury duty, unpaid personal) to classify leave for reporting and benefits decisions.

Dates and Schedule

Start and end dates plus partial-day times where relevant to calculate accruals, overtime impact, and payroll adjustments.

Reason Summary

Short, factual description of the personal reason; avoid sensitive medical detail unless required and permitted.

Approvals

Manager and HR approval fields with signature, printed name, and date to document authorization and any conditions.

Payroll Instructions

Fields for pay status (paid, unpaid, use PTO) and routing to payroll to ensure correct pay treatment.

Step-by-Step: Submitting a Leave Request

Complete and route the form in this order to reduce processing time and maintain accurate records.

  • 01
    Fill form: Complete all required fields and attach context if needed.
  • 02
    Choose pay option: Indicate PTO, unpaid leave, or other pay treatment.
  • 03
    Sign: Sign electronically or in ink and date the form.
  • 04
    Submit: Send to your manager and HR via the defined channel.

Configuring an Online Leave Request Workflow

Set up fields, approvals, and integrations to automate routing and payroll handoffs when using an electronic form.

Field Configuration
Required Fields Employee name, ID, dates, leave type
Approval Steps Manager then HR sequential approval
Notifications Email or in-app alerts to approvers
Payroll Integration Map leave type to payroll code

Where to Send or File the Completed Form

Knowing the correct submission channel ensures timely approvals and accurate payroll adjustments.

  • Direct Manager: Primary reviewer for operational approval and scheduling.
  • Human Resources: Final approver for policy compliance and recordkeeping.
  • Payroll Department: Receives final instructions for pay treatment and deductions.
  • HRIS / Employee File: Store signed copy in personnel record for retention requirements.

Technical Options for Electronic Submission

Ensure the chosen platform preserves an audit trail and stores records securely to meet legal and company retention policies.

  • File formats: PDF, DOCX supported
  • Integrations: HRIS, payroll, and cloud storage
  • Signer authentication: Email, SMS, or stronger methods

Timing, Notice, and Processing Expectations

Set clear timelines for employee notice, manager response, payroll processing, and record retention to avoid administrative issues.

Employee Notice Window:

Follow employer policy; typical advance notice is 1–14 days

Manager Response Time:

Recommend 2–5 business days for initial decision

Payroll Cutoff:

Submit approved requests before payroll cutoff to affect pay

Effective Leave Date:

Dates on the form determine benefit and accrual impact

Record Filing:

Signed requests file in HRIS immediately after approval

Common Mistakes to Avoid

  • Incomplete dates or time ranges causing payroll miscalculations and resubmission delays.
  • Mismatched employee names or IDs that prevent matching to payroll and delay processing.
  • Choosing the wrong leave category and triggering unintended policy reviews or benefits changes.
  • Failing to sign or use an authorized e-signature method leaving the request invalid for payroll action.

Consequences of Incorrect or Missing Information

Payroll Errors: Overpayment or underpayment risk
Delayed Approval: Operational disruption and scheduling gaps
Policy Violation: Possible disciplinary action
Privacy Breach: Sensitive data exposure risk
Tax Withholding Issues: Incorrect payroll taxes applied
Recordkeeping Failure: Noncompliance penalties

Typical eSignature Pricing and Features for Leave Workflows

Compare starting prices and common features relevant to HR forms. signNow is listed first for direct feature and price comparison.

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 No No Yes, limited Yes, limited
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Required Data Elements and Security Notes

Employee Name: Full legal name required
Employee ID: Payroll identifier
Leave Dates: MM/DD/YYYY range
Pay Treatment: Paid, unpaid, or PTO
Approver Signature: Manager and HR signatures
Storage: Retain in HRIS with access controls

Real-World Examples of Electronic Leave Requests

Organizations use electronic forms to speed approvals and maintain audit trails while keeping records centralized and searchable.

Martin Properties — Tim Martin

Tim Martin found online execution reliable for operational documents

  • Rapid web-based signing cut in-person handoffs
  • The company uses electronic forms to process requests and return signed records to managers and HR quickly while maintaining compliance.

Optica Ventures — Brian Fitzgibbons

Optica adopted digital forms for routine HR tasks

  • Employees complete requests remotely with consistent fields
  • That simplicity improved turnaround and reduced administrative back-and-forth for the HR team while preserving clear approval records.

Practical Tips to Keep Processing Smooth

Apply these operational tips to reduce mistakes and speed approvals when managing discretionary leave requests.

Standardize Fields
Use fixed-choice fields for leave type and pay treatment to prevent classification errors and ease reporting.
Validate IDs
Require employee ID validation to match payroll and reduce reconciliation work.
Set SLAs
Establish target response times for managers and HR to manage expectations and staffing.
Secure Storage
Protect records with role-based access and retain per retention schedule.

Frequently Asked Questions and Troubleshooting

Answers to common questions about completing, routing, and retaining Personal Discretionary Leave Request Forms.


Need help? Contact support

Explore Templates

Change Order Form EZ-Fax Order Form Untitled Document Evidence to Support Variation of a Support Order Stalking Order Form Texas Order Form
be ready to get more
Join over 28 million airSlate SignNow users
Sign Now
Company
Forms
Pricing
Resources
Knowledge base
Other Products
© 2026 airSlate Inc. All rights reserved.