Leave of absence request form
A leave of absence request for an extended period: start and return dates, reason, paid or unpaid, and approvals.
- 🇺🇸 US format · Letter size
- Free
This is a sample form. Check that the terms and pay match federal and state labor rules and your company policy.
Fill in what you need. The preview updates as you type.
What you type is not saved on our server.
Your company policy comes first
Time off, leave and travel approvals follow your employee handbook and your state's rules. If your employer has its own form, use that one. This template is a quick way to draft the same information and is not legal advice.
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Leave of Absence Request
| Manager | Human Resources |
| Employee | Jordan Lee | Department | Marketing, Associate |
|---|---|---|---|
| Employee ID | EMP-0231 | Date | October 5, 2026 |
| Type of leave | ■ Medical □ Family care □ Education □ Personal □ Other | ||
| Paid or unpaid | □ Unpaid □ Paid ■ Paid, then unpaid | ||
| Dates of leave | November 2, 2026 to January 29, 2027 (2 months 28 days) | ||
| Expected return date | January 30, 2027 | ||
| Reason | I am scheduled for surgery on November 3 and my doctor expects a recovery period of about twelve weeks. I will use my remaining PTO for the first two weeks and request unpaid leave for the rest. A note from my doctor is attached. | ||
| Backup contact | Sam Park, Marketing | Contact while away | (555) 010-0000 |
| Mailing address during leave | 123 Main St, Apt 4, Austin, TX 78701 | ||
I request a leave of absence as described above and understand that approval, pay and benefits during the leave follow company policy. October 5, 2026 Employee signature: Jordan Lee To: Human Resources | |||
How to use it
Pick the type of leave, say whether it is paid or unpaid, and type the first and last day. The form adds the length of the leave and sets the expected return date to the day after the last day unless you type a different one. In the reason box, say what the leave is for, what documents you are attaching, and how you plan to use PTO or sick time if the leave is partly paid.
Give the name of the person covering your work, a way to reach you, and a mailing address if it differs from the one on file. The sign-off boxes are for your manager and HR.
Things to watch
If the leave may qualify under the Family and Medical Leave Act, tell HR when you submit this. FMLA has its own federal certification forms (the WH-380 series) that your employer gives you, and this request does not replace them. Benefits, health insurance premiums and your job status during an unpaid leave follow your employee handbook, so read that section before you pick dates.
Calculators that go with this
Frequently asked questions
Is this the FMLA form?
No. FMLA leave uses federal forms that your employer provides, such as WH-380-E for your own condition or WH-380-F for a family member. Use this request to tell your employer what you need; HR will give you the FMLA paperwork if it applies.
What if I do not know the last day yet?
Type your best estimate and say so in the reason box. Most employers will ask for an updated request if the leave needs to be extended. The expected return date can be left empty and written in later.
How many sign-off boxes do I need?
Match your company's approval chain. A small team often uses one box for the manager. Larger companies add Reviewed by and Approved by. Pick None if approvals happen by email and you only need the body of the form.
Is what I type saved anywhere?
No. Everything stays in your browser and nothing is sent to our server. If you refresh the page it is gone, so print, save a PDF or download the DOCX when you are done.