MAKE THE DOCUMENT WORK FOR YOUR SITUATION
About this time off request form
Record dates, coverage arrangements, and the status of a request without turning a manager’s approval field into a legal eligibility decision.
When to use it
- Use for scheduling and documenting ordinary leave requests.
- Route potentially protected leave through the appropriate statutory and accommodation process as well.
What to gather before completing it
- Identify requested dates, hours, scheduling needs, and the appropriate leave contact.
- Review whether statutory leave, sick time, or accommodation may apply before relying on the balance.
- Keep required certifications in a suitable private process and reference them without including a diagnosis here.
Common mistakes to avoid
- Rejecting a potentially protected request solely because no vacation balance remains.
- Requiring every employee to disclose detailed medical information to a manager.
- Treating this form as the actual FMLA, PFML, or other program notice and application.
After you complete the document
- Provide a clear status and distinguish scheduling approval from separate statutory determinations.
- Deliver any required program notices and document the leave designation.
- Update coverage and attendance records and review changes in dates through the correct process.
What the template includes
The online builder and downloaded documents use the same fields. A selected state can add relevant research prompts. Complete only applicable items; add explanations for exceptions rather than assuming a blank entry resolves them.
Document details4 inputs +
Set the date, jurisdiction, and your internal reference.
- Document date *
- US state *
- County
- Document reference
Work location & legal coverage5 inputs +
Record the actual facts, reviewed rule, and supporting references. No answer here certifies a waiver, exemption, restriction, or deadline as valid.
- States where work is actually performed
- Local workforce rules and official references
- Employer size and coverage facts reviewed
- Applicable collective agreement or representation
- Reviewed rule and dated source reference
Protected leave & accommodation review8 inputs +
Record the actual facts, reviewed rule, and supporting references. No answer here certifies a waiver, exemption, restriction, or deadline as valid.
- Potential protected leave category and coverage reviewed
- Eligibility facts and reviewed decision basis
- Absences excluded from attendance scoring or discipline
- Requested adjustment and discussion record without diagnosis
- Essential functions and work restrictions reviewed
- Required separate notices and delivery references
- Private supporting record reference without medical details
- Leave or accommodation decision contact
Employment details13 inputs +
Use accurate facts and apply your organization’s policies consistently.
- Employee name *
- Department
- Manager *
- Leave type
- First leave date *
- Last leave date *
- Total hours requested
- Available balance (hours)
- Reason (optional)
- Backup coverage and handover *
- Urgent contact arrangements
- Decision
- Manager comments
Additional details & signing7 inputs +
Add attachments, exceptions, and the names of authorized signers.
- Attachments / supporting records
- Exceptions / additional terms
- First signer printed name
- First signer title
- Second signer printed name
- Second signer title
- Signing date
Practical tips
- Be specific. A clear description is easier to verify than a broad label.
- Download Word if you need to add an attachment or adjust the layout.
- Keep the completed document and supporting records together.
Before signing or submitting
Employment, wage, leave, privacy, and separation requirements depend on location and circumstances. Verify the applicable rules and avoid including unnecessary medical or sensitive information.