Request extended time away from work, with dates, reason category, supporting documents and return plan.
Extended leave may fall under federal, state or local law, such as family and medical leave, military leave or jury duty, or under your own policy. The rules, notices and deadlines differ.
Ask only for the information needed to decide. Medical details should go to HR, not the line manager, and be stored separately.
14 items. Fill it in on screen or print a copy.
A line cook requests six weeks of leave after the birth of a child. HR checks eligibility, sends the required notices, and the manager plans coverage with two part-timers picking up extra shifts.
Leave requests can trigger legal duties, such as eligibility and rights notices under the FMLA for covered employers, plus state family leave and paid sick leave laws. A dated request and decision show the employer responded within the required time and applied the same rules each time.
| Employee and role | Priya, dental assistant, Lakeview Family Dental, Columbus |
|---|---|
| Type of leave | Medical, own surgery |
| Start and expected return | June 9 to July 21 |
| Continuous or intermittent | Continuous, then two half days for follow-ups |
| Paid leave to use | 40 hours PTO first, then unpaid |
| Contact during leave | Personal email, weekly check-in on Fridays |
| HR decision | Approved; eligibility and rights notice sent June 2 |
The request combines a continuous block with two later half days, so the form records both patterns instead of forcing the follow-up visits into a separate request.
Depends on employer size, location and leave type. Get advice.
Within limits set by law.
For some types of leave, yes.
Often, depending on policy and law.
Intermittent leave is taken in separate blocks, such as one day a week for treatment, rather than all at once. Under the FMLA it can be taken for a serious health condition when medically necessary, and the employer can track it in small increments. Marking it on the form helps the manager plan recurring coverage instead of one long gap.
When the need is foreseeable, the FMLA generally expects 30 days’ notice, such as for a planned surgery or birth. When it is not foreseeable, notice is due as soon as practicable, often the same or next business day. Your own policy and state laws may add other rules, so the form should record the date the request was received.
More for the same job
Employees can fill in and sign forms like this in the EZTime app, and the signed copy lands in their digital employee file. Try it for 14 days, no credit card.