1. Full Name
2. Type of Leave
3. First Day of Leave (if leaving early go to Q4)
Last Day of Leave (if applicable)
Return to Work Date (if applicable)

How many days Annual Leave will you be taking ?

4. 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.