Do I have to disclose my medical reason for sick leave?

No. Under FMLA and most state leave laws, employees are not required to provide specific medical diagnoses. You may write 'medical reasons' or 'health-related leave.' Your employer may request a doctor's note confirming that you are unable to work, but cannot demand specific diagnoses.

Can my employer deny my leave request?

Employers can deny non-protected leave requests (vacation, personal) based on business needs. However, employers generally cannot deny FMLA leave, ADA accommodation leave, or other legally protected leave. Consult your state's labor laws for additional protections.

Does unpaid leave affect my benefits?

FMLA leave requires employers to maintain group health benefits during the leave period. For non-FMLA unpaid leave, benefit continuation depends on your employer's policy. Check with HR about the impact on health insurance, retirement contributions, and PTO accrual.

What is the difference between FMLA and state family leave?

FMLA is federal law providing up to 12 weeks unpaid leave for covered employers and eligible employees. Many states have additional paid family and medical leave programs (e.g., California, New York, Washington). State programs may have different eligibility rules, benefit amounts, and qualifying reasons.

Free Leave Request Form Template — Fill Out & Download Instantly

Free — No Sign-Up RequiredPDF & WordContent date March 21, 2026

⚠️ Important: This is a general informational template, not legal advice or a guarantee of validity. Requirements vary by state and situation. Verify current official requirements and seek a licensed attorney for consequential matters. Review our sources and methodology.

Document Completeness0%

Employee Full Name*

Employee ID (if applicable)

Department*

Supervisor / Manager Name*

Type of Leave Requested*

Leave Start Date*

MM/DD/YYYY

Leave End Date*

MM/DD/YYYY

Total Working Days Requested*

Reason for Leave*

Medical details are confidential and not required. Brief description is sufficient.

Coverage Arrangements During Absence*

Describe how your work responsibilities will be managed while you are away

Request Submission Date*

MM/DD/YYYY

Live Preview

100%

EMPLOYEE LEAVE REQUEST FORM

EMPLOYEE INFORMATION

Employee Name: [Employee Full Name]

Department: [Department]

Supervisor: [Supervisor / Manager Name]

Request Date: [Request Submission Date]

LEAVE REQUEST DETAILS

Type of Leave: [Type of Leave Requested]

Leave Start: [Leave Start Date]

Leave End: [Leave End Date]

Total Days: [Total Working Days Requested] working day(s)

Reason for Leave:

[Reason for Leave]

Coverage Arrangements During Absence:

[Coverage Arrangements During Absence]

EMPLOYEE CERTIFICATION

I certify that the information provided above is accurate and that I have reviewed my current leave balances and company leave policy.

Employee Signature: ___________________________ Date: ___________

SUPERVISOR / HR ACTION

[ ] APPROVED

[ ] DENIED — Reason: ________________________________________

[ ] APPROVED WITH MODIFICATION: _____________________________

Supervisor Signature: _________________________ Date: ___________

Printed Name: _______________________________________________

HR Signature (if required): ___________________ Date: ___________

Document Completeness0%

Employee Full Name*

Employee ID (if applicable)

Department*

Supervisor / Manager Name*

Type of Leave Requested*

Leave Start Date*

MM/DD/YYYY

Leave End Date*

MM/DD/YYYY

Total Working Days Requested*

Reason for Leave*

Medical details are confidential and not required. Brief description is sufficient.

Coverage Arrangements During Absence*

Describe how your work responsibilities will be managed while you are away

Request Submission Date*

MM/DD/YYYY

What Is a Leave Request Form?

A leave request form is an official HR document used by employees to formally request time off from work. It captures the type of leave requested (vacation, sick leave, personal leave, bereavement, parental leave, or unpaid leave), the dates and total number of days requested, the reason for the leave, and any coverage arrangements made during the absence. Using a standardized leave request form helps HR departments track paid time off (PTO) balances, ensure adequate staffing coverage, and maintain proper documentation for compliance with the Family and Medical Leave Act (FMLA), state leave laws, and company policies..

When Do You Need It?

Employees should submit a leave request form before taking planned time off — typically 2–4 weeks in advance for vacation and personal leave. For unplanned sick leave, a form should be submitted upon return or as soon as practicable. FMLA leave requests should be submitted at least 30 days in advance when the need is foreseeable.

What's Included in This Template

Employee name, ID, and department
Supervisor name
Leave type selection (vacation, sick, personal, bereavement, maternity/paternity, unpaid)
Leave start and end dates
Total days requested
Reason for leave
Coverage arrangements during absence
Request date and employee signature line
Supervisor approval/denial section

How to Fill It Out

Enter Employee Information — Fill in your full name, employee ID (if applicable), department, and your direct supervisor's name. This identifies who is making the request.

Select Leave Type — Choose the category that best describes your leave: vacation, sick leave, personal, bereavement, maternity/paternity, or unpaid leave. This determines which PTO balance will be debited.

Enter Dates and Days — Enter the first and last date of your requested leave and the total number of working days being requested. Exclude weekends and holidays from the count.

Provide Reason and Coverage — Briefly explain the reason for your leave (medical reasons may be kept confidential for HIPAA/privacy purposes). Describe how your responsibilities will be covered in your absence.

Submit to Supervisor — Download and sign the form, then submit to your supervisor or HR department per your company's leave policy. Keep a copy for your own records.

Legal Requirements & Notes

Employee leave is governed by a combination of federal law, state law, and company policy. Key considerations: - **FMLA**: The Family and Medical Leave Act (29 U.S.C. § 2601 et seq.) requires covered employers (50+ employees) to provide eligible employees up to 12 weeks of unpaid, job-protected leave for qualifying reasons. Employees must provide 30 days advance notice when leave is foreseeable. - **State Leave Laws**: Many states have leave laws that exceed FMLA protections: California (CFRA), New York (NYPFL), Washington (PFML), and others provide paid family and medical leave. Check your state's labor department for specific requirements. - **ADA Accommodation**: For disability-related leave, the Americans with Disabilities Act (ADA) may require employers to provide additional unpaid leave as a reasonable accommodation, beyond FMLA entitlements. - **Retaliation Prohibition**: Federal and state laws prohibit retaliation against employees for taking legally protected leave. Employers should not discipline, demote, or terminate employees for exercising leave rights. - **Documentation**: Employers should retain leave request forms for the duration of employment plus 3–7 years depending on state requirements. FMLA documentation must be retained for at least 3 years.

Frequently Asked Questions

For planned leave (vacation, personal), submit your request at least 2–4 weeks in advance per your company's policy. For FMLA leave, federal law requires 30 days advance notice when the need is foreseeable. For emergency or unplanned sick leave, notify your supervisor as soon as possible and submit the form upon return.

Free Leave Request Form Template — Fill Out & Download Instantly

EMPLOYEE LEAVE REQUEST FORM

EMPLOYEE INFORMATION

LEAVE REQUEST DETAILS

EMPLOYEE CERTIFICATION

SUPERVISOR / HR ACTION

[ ] APPROVED

What Is a Leave Request Form?

When Do You Need It?

What's Included in This Template

How to Fill It Out

Legal Requirements & Notes

Frequently Asked Questions

Related Templates

Two Weeks Notice Letter

Employee Write-Up Form

Termination Letter Template