Time Off Request Form

Employee Information

Full Name:
[EMPLOYEE_FULL_NAME]

Employee ID:
[EMPLOYEE_ID_NUMBER]

Department / Team:
[DEPARTMENT_NAME]

Job Title:
[JOB_TITLE]

Manager / Supervisor Name:
[MANAGER_FULL_NAME]

Work Email Address:
[EMPLOYEE_EMAIL_ADDRESS]

Work Contact Number (during leave, if applicable):
[CONTACT_PHONE_NUMBER]

---

Request Details

Type of Time Off Request:
Please select one of the following:

• Annual Leave / Vacation
• Sick Leave / Personal Illness
• Personal Days
• Bereavement
• Jury Duty / Civic Duty
• Parental Leave (Maternity/Paternity)
• Family Care Leave
• Unpaid Leave
• Other: [PLEASE_SPECIFY_TYPE]

Date of Submission:
[DATE_OF_SUBMISSION]

---

Leave Schedule

Start Date of Leave:
[START_DATE]

End Date of Leave:
[END_DATE]

Time of Departure on First Day (if applicable):
[START_TIME]

Time of Return on Last Day (if applicable):
[RETURN_TIME]

Total Number of Working Days Requested:
[TOTAL_DAYS_REQUESTED]

Total Number of Working Hours Requested:
[TOTAL_HOURS_REQUESTED]

Is this request for a half-day?

• Yes (Morning)
• Yes (Afternoon)
• No, Full Day(s)

---

Return to Work

Scheduled First Day Back at Work:
[RETURN_TO_WORK_DATE]

Will you be available for emergency contact during this leave?

• Yes
• No

If yes, please provide the best method of contact:
[PREFERRED_EMERGENCY_CONTACT_METHOD]

---

Handover and Coverage Plan

Primary Coverage (Who will cover your essential duties?):
[COVERAGE_PERSON_NAME]

Brief Description of Tasks/Responsibilities to be Handled:

1. [TASK_DESCRIPTION_1]
2. [TASK_DESCRIPTION_2]
3. [TASK_DESCRIPTION_3]
4. [TASK_DESCRIPTION_4]

Location of Key Files/Resources needed for coverage:
[FILE_PATH_OR_RESOURCE_LOCATION]

Specific Instructions or Deadlines for the coverage person:
[COVERAGE_INSTRUCTIONS]

Status of Current Projects:

• All projects are up to date.
• Some projects require attention prior to leave; details below:
  [PROJECT_NOTES]

---

Additional Information / Reason for Request

Reason for Leave (Optional for Vacation, Required for Sick/Bereavement):
[REASON_FOR_LEAVE]

Additional Comments or Special Requests:
[ADDITIONAL_COMMENTS]

---

Leave Balance Confirmation (Optional / Pre-filled by Payroll)

Current Leave Balance (Days/Hours) prior to this request:
[CURRENT_BALANCE]

Remaining Leave Balance (Days/Hours) after this request (if approved):
[REMAINING_BALANCE]

---

Approval Section

Employee Signature:

---

Date: [DATE_SIGNED]

---

Manager / Supervisor Approval:

• Approved
• Approved with Conditions (Conditions noted below):
  [CONDITIONS_OF_APPROVAL]
• Declined (Reason noted below):
  [DECLINE_REASON]

Manager Signature:

---

Name: [MANAGER_PRINTED_NAME]
Date: [MANAGER_APPROVAL_DATE]

---

Human Resources Review:

• Recorded
• Noted (Requires further action)

HR Representative Signature:

---

Date: [HR_REVIEW_DATE]