How to use itKeep it short and approve quickly. Apply your bereavement policy, and check whether your state requires bereavement leave.
Who fills it inThe employee, or the manager on their behalf
WhenAs soon as the employee can share the news
Time neededA couple of minutes, often by phone
Keep itLeave records, with minimal personal detail
Where the bereavement leave request form fits
Bereavement is not the time for paperwork, so the form should take a minute. A manager can complete it with the employee by phone.
Federal law does not require bereavement leave, but some states do. Your policy sets pay and eligible relationships.
9 items. Keep it on a tablet, or print a copy for the clipboard.
Request
Pay
Approval
How to use the bereavement leave request form step by step
Make the form easy to complete by phone.
Approve quickly.
Arrange coverage without involving the employee.
Follow up with care.
Keep documentation requests minimal.
A real-world example
A server’s grandmother dies on a Saturday. The manager calls, fills in the form for three paid days under the policy plus one unpaid travel day, and arranges cover for the shifts.
Why keep a bereavement leave request form
The form records which days are paid under the policy and which come from PTO or are unpaid, so payroll gets the check right while the employee is away. Applying the same written rules to each request also helps avoid claims that one person was treated more generously than another.
A filled-in bereavement leave request form
Employee and role
Nadia, bookkeeper
Relationship
Father-in-law
Leave dates
January 13 to January 16
Travel day
January 17
Paid under policy
3 days
Additional days
1 day PTO, travel day unpaid
Approved by
Greg, office manager, January 12
Sample for Pinecrest Accounting in Boise, Idaho. In-laws are not on every policy’s list, so the manager checked before approving, and the extra time is split between PTO and unpaid so Nadia keeps some PTO.
Common bereavement leave request form errors
Asking for a death certificate or obituary as a default. If your policy allows proof, ask only when there is a real reason.
Applying a narrow list of relatives with no flexibility. Allow the manager to approve leave for a close friend or chosen family, using PTO if needed.
Calling the employee to cover shifts during their leave. Arrange coverage among the team so the grieving person is left alone.
Changing the bereavement leave request form for your workplace
Employees with family abroadAllow extra unpaid or PTO days for international travel and flexibility for a delayed funeral date.
Small teamsHave the owner make the coverage plan within a day so the rest of the team is not left guessing.
Pro tipSend a short written confirmation of approved days and pay after the call. In a hard week the employee will not remember the details you said.
What people ask about the bereavement leave request form
Is bereavement leave required?
Not under federal law; some states require it.
Is it paid?
Depends on your policy and state.
Which relationships qualify?
Set in your policy.
Can I ask for proof?
Many policies allow it, but use discretion.
Can bereavement leave be split instead of taken all at once?
Many policies allow it, for example one day after the death and two more for a memorial weeks later. Set a window, such as within three months of the death, and write each set of dates on the form.
Does bereavement leave cover a pregnancy loss?
That depends on your policy and your state. Illinois and California now require leave after certain reproductive losses, so check local rules and consider naming these losses in the policy so employees do not have to ask.
Once the bereavement leave request form is in place, the next question is usually about shifts and hours. Book a demo to see how EZTime handles scheduling and time tracking.
Disclaimer: This template is general information, not legal advice. Employment rules differ by state and city and change over time. Have a qualified employment attorney or HR professional review it before you use it.
