Paid Time Off (PTO) Leave Request Form

Date of request: ______________   Employee name: _______________________

           
Department: _________________     Job title: _____________________________

PTO (Vacation/sick leave)

Start date: ________  End date: ________   Total hours: ________

Bereavement leave (Up to three days of paid leave due to a death in the immediate family is available.)

Start date: ________  End date: ________   Total hours: ________

Jury duty leave (Up to five days of paid leave for jury service is available.)

Start date: ________  End date: ________   Total hours: ________

Other

Policy name (e.g., sabbatical leave, school visitation, etc.): ____________________________

Start date: ________  End date: ________   Total hours: ________

This form should not be used to request leave under the Family and Medical Leave Act (FMLA) or to request leave as an accommodation under the Americans with Disabilities Act (ADA). Employees should consult with HR to request leave under the FMLA or ADA.

________________________________________      __________________
Employee signature                                                            Date

________________________________________      __________________
Supervisor signature                                                           Date

________________________________________      __________________
Human resources representative signature                      Date

File original in the employee's leave records and provide a copy to the employee and the employee's supervisor.