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Medical Leave Application Form

The leave application form collects an employee's personal information and the type of leave being requested, along with the dates and reason for leave. It also tracks the employee's annual and medical leave balances before and after the requested leave. Department approval is required before the leave application is submitted to Human Resources.

Uploaded by

Billy Eres
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598 views1 page

Medical Leave Application Form

The leave application form collects an employee's personal information and the type of leave being requested, along with the dates and reason for leave. It also tracks the employee's annual and medical leave balances before and after the requested leave. Department approval is required before the leave application is submitted to Human Resources.

Uploaded by

Billy Eres
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Leave Application Form

LEAVE APPLICATION / MEDICAL LEAVE FORM

NAME: _________________________________ STAFF NO: _________________________________________

DESIGNATION: __________________________ DEPARTMENT: ______________________________________

Type of leave (please tick the appropriate box)

Vacation Leave No Pay Leave Maternity / Paternity

Sick Leave Emergency Leave Hospitalization Leave Marriage Leave

Compensatory Time Off Compassionate Leave Prolong Illness Leave Examination Leave

From ________________________ to ______________________ No. of working days _____________________

Reason _______________________________________________________________________________________

Contact Address & Tel No. During Leave:

____________________________________________________________________________________________

Annual Leave Record No. of Days ______________________________________________


Name and Signature of Applicant
Date: _____________________________
Leave Credit from last year
Received & Recorded by:

Total leave entitlement ______________________________________________


Name and Signature of Immediate Superior
Date: _______________________________
Less: leave taken to date
Approved / Not Approved
Balance Leave Available
______________________________________________
Head of Department
Less: leave applied for Date: _____________________________
Remarks (if not approved)

New leave balance ______________________________________________

REMARKS: Verified by:

______________________________________________
People Department
Date: _______________________________
NOTE:
1. Your medical leave must be submitted to your Department Head no later than 48 hours from the date of the MC
2. The medical certificate (s) must be submitted with this leave form
3. Kindly attach relevant document(s) to support all other leave

LEAVE APPLICATION / MEDICAL LEAVE FORM NAME: _________________________________ STAFF NO: ________________________________

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