Sick leave request form
A sick leave request with dates, whether a doctor's note is attached and who covers your work.
- ๐บ๐ธ US format ยท 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.
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Sick leave rules depend on your state and employer
There is no federal paid sick leave law for private employers, but many states and cities require paid sick time and limit when a doctor's note can be requested. Your employee handbook says how sick time is earned and used. This form records the request and is not legal advice.
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Sick Leave Request
| Manager | Human Resources |
| Employee | Jordan Lee | Department | Marketing, Associate |
|---|---|---|---|
| Employee ID | EMP-0231 | Date | October 5, 2026 |
| Dates | October 12, 2026 to October 16, 2026 (5 days, workdays only) | ||
| Time charged to | โ Paid sick timeย ย โก PTOย ย โก Unpaid | ||
| Doctor's note | โ Attachedย ย โก Will provideย ย โก Not required | ||
| Reason | My doctor has advised five days of rest after a back injury. A note with the dates is attached. I will check email once a day for anything urgent. | ||
| Backup contact | Sam Park, Marketing | Contact while away | (555) 010-0000 |
I request sick leave for the dates above. October 5, 2026 Employee signature: Jordan Lee To: Human Resources | |||
How to use it
Type the first and last day and the form counts the days, skipping weekends unless you turn that option off. Pick how the time should be charged (paid sick time, PTO or unpaid) and whether a doctor's note is attached, coming later, or not needed. The reason box is optional; a line about how long you expect to be out is usually enough.
Name the person covering your work and how to reach you if something cannot wait. Submit to HR or your manager, whichever your handbook says.
Things to watch
You do not have to write a diagnosis on the form. If your employer asks for a doctor's note, a note that states the dates you need off is enough in most cases. For an illness that will keep you out for weeks, use the leave of absence request instead, and ask HR whether FMLA applies.
Calculators that go with this
Frequently asked questions
Do I have to say what is wrong with me?
No. Give the dates and, if your employer asks, a doctor's note. Medical details are yours to keep. Many state sick leave laws also limit what an employer can ask for.
What if I am already out sick?
Date the form the day you fill it in and set the first day to the day you started missing work. Most employers accept a sick leave request after the fact as long as you called in.
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.