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Leave of Absence Request Form & Letter
Leave of absence request form, personal and medical leave letter samples, and an HR checklist with FMLA notice deadlines and state paid leave notes.
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What you get
- A one-page request form covering FMLA, medical, family, military, personal and state leave
- Two letter samples: a personal leave of absence request and a medical leave letter
- An HR processing checklist with the FMLA 5-business-day and 15-calendar-day clocks
- A benefits-continuation and return-to-work section
- A list of state paid family and medical leave programs to check
Template preview
A preview of the structure. Download the PDF or CSV for the complete, ready-to-use version.
Section 1: Employee details
- Employee name and ID
- Job title and department
- Manager
- Work location (state)— Determines which state leave laws apply
Section 2: Type of leave requested (check all that may apply)
- Own serious health condition (including pregnancy and childbirth recovery)
- Care for a spouse, child or parent with a serious health condition
- Bonding with a new child (birth, adoption or foster placement)
- Military family leave: qualifying exigency or military caregiver leave
Section 3: Leave details
- Leave start date
- Expected return date
- Schedule— Continuous / intermittent / reduced schedule
- If intermittent or reduced: expected pattern— e.g. 2 half-days per week for physical therapy for 8 weeks
Section 4: HR use only
- Date HR learned of need for leave— Starts the 5-business-day clock
- FMLA eligible?— 50+ employees within 75 miles; 12 months of service; 1,250 hours in last 12 months
- FMLA hours/weeks used in current 12-month period
- State leave law(s) that apply
Sample letter: request for a personal leave of absence
[Your name] [Date] Dear [Manager name], I'm writing to request an unpaid personal leave of absence from [Start date] to [End date], a total of [number] weeks. [One sentence of reason if you are comfortable sharing it, e.g. 'I need to relocate temporarily to help my family after a house fire.'] Before I leave, I will [hand over specific work, e.g. finish the Q3 audit and brief Jordan on the three open vendor disputes]. I'd like to use my [number] days of accrued PTO at the start of the leave and take the remainder unpaid. I understand that approval depends on business needs and our leave policy. I'm happy to discuss dates or a shorter leave if that would help. I can be reached at [personal email] and [phone] while I'm away. Thank you for considering my request. Sincerely, [Your name]
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How to use this template
- 1
Employee completes Sections 1–3
Give notice 30 days ahead when leave is foreseeable, or as soon as practicable when it is not. Medical details are not needed on the form; the certification from the health care provider covers that.
- 2
HR screens every request for protected leave
Check FMLA eligibility, state leave laws, ADA accommodation and workers' comp even if the employee only asked for 'time off'. The employer, not the employee, has to spot a potentially protected reason.
- 3
Send notices on time
Issue the FMLA eligibility notice and rights and responsibilities notice within 5 business days of learning of the need for leave, then the designation notice within 5 business days of receiving enough information.
- 4
Agree benefits and contact arrangements
Confirm how premiums will be paid during unpaid leave, who the employee's HR contact is and how often you will check in.
- 5
Plan the return
Confirm the return date in writing, request a fitness-for-duty certification only if your uniform policy requires it and you gave notice in the designation, and restore the employee to the same or an equivalent job.
Frequently asked questions
How do I write a leave of absence letter?
Address it to your manager or HR, state the start and expected end dates, give a brief reason without medical detail, say whether you want to use accrued PTO, explain how your work will be covered and give contact details. Offer to discuss the dates. For medical leave, ask whether FMLA or state leave applies and what certification is needed.
What should a leave of absence request form include?
Employee details and work state, the type of leave, start and return dates, whether leave is continuous or intermittent, use of paid leave, a general reason and a signature. An HR section records FMLA eligibility, state laws that apply, the dates notices were sent, certification due dates and the benefits arrangement.
How long does an employer have to respond to an FMLA request?
The employer must give the eligibility notice and the rights and responsibilities notice within five business days of learning that the employee may need FMLA-qualifying leave, and the designation notice within five business days of having enough information, usually after the certification comes back.
Can an employer deny a leave of absence?
An employer cannot deny leave that is protected by the FMLA, a state leave law, USERRA or workers' compensation for an eligible employee, and must consider leave as a possible ADA or PWFA accommodation. Purely personal leave that is not protected by law can be approved or denied under company policy, applied consistently.
Is a leave of absence paid?
FMLA leave is unpaid, but employees can use or be required to use accrued paid leave at the same time. Income may also come from a state paid family and medical leave program, short-term disability insurance, or workers' compensation. Personal leave is usually unpaid unless company policy says otherwise.
Do I have to tell my employer my diagnosis?
No. A general reason such as 'surgery and recovery' is enough on the request. For FMLA leave, the health care provider completes a certification with medical facts sufficient to support the need for leave, and the employer must keep it confidential and separate from your personnel file.