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Leave of Absence Form - Rev. 2012
EMPLOYEE LEAVE APPLICATION FORM
Employee Name: Position:
Facility Assigned: Date Filed:
Date Covered: From: to No. of Days:
Date of Return to Work:
Leave to be Applied:
Vacation Leave Bereavement Authorized Leave Without Pay
Other:
I understand that:
1. All leave of absence application must be approved by the Supervisor or DNS of the assigned facility.
2. Leave due to sickness/medical reason of more than 2 days must be supported by doctor’s certificate
and must be filed upon return to work/duty;
3. Bereavement leave must be supported by pertinent documents (Death Certificate or Funeral Letter);
4. Planned leave application of 3 days or more must be filed 2 weeks in advance.
5. Alteration / Cancellation of applied leave must have the approval of my supervisor and that Advanced
Care Staffing Representative or Account Manager must be properly notified.
I hereby request leave of absence from duty as indicated above and certify such leave/absence is requested
for the purpose(s) indicated. I understand that I must comply with my employing agency’s policies and
procedures for requesting leave of absence (and provide additional documentation, including medical
certification, if required) and that falsification on this form may be grounds for disciplinary action, including
termination.
Employee signature: Date:
Approved by: , Supervisor/DNS/ADNS Date:
Account Manager: Date:
266 Broadway Suite 502
Brooklyn, NY 11211
(T) 718 305 6700
(F) 718 305 6824
www.advancedcarestaffing.com
We take staffing close to heart.
PREVIOUS BALANCE
DATE POSTED:
FOR HR DEPARTMENT USE ONLY
LESS: APPLIED LEAVE
BALANCE TO DATE
EARNED
CREDITS
LEAVE STATUS
WITH PAY
WITHOUT
PAY
POSTED BY:
PROCESSED BY: