Date to Start Leave
Date Returning to Work

Total Number Of Working Days

Type of Leave
Employee Signature
Approved by Foreman
Management Approval (Office Use Only)
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.