Full name

Dates of Leave

Total Number Of Working Days

Return to Work Date

Type of Leave
Hours Left Early (if applicable)
Employee Signature
Approved by Peter Harris
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.