Leave Request Form
This form is used to request leave
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Staff Name and ID
Staff Designation
Leave Requested From
MM
/
DD
/
YYYY
Leave Requested To
MM
/
DD
/
YYYY
Total Leave Days Requested
Type Of Leave, select all that apply
Itinerary ( include locations to be visited and date)
Contact method during leave (provide the easiest way to contact you by telephone or email)
Date of return to duty
MM
/
DD
/
YYYY
Approval by immediate Supervisor (1) : Name of supervisor and ID
Approval decision (select one)
Approved From Date
MM
/
DD
/
YYYY
Approved To Date
MM
/
DD
/
YYYY
Number of days approved
Signature of immediate supervisor
Comments, if any, such as modified work arrangements
Approval by Director of Nursing and Human Resources (2)
Reasons if declined
Number of days if approved
Comments if any
Signature of Director
Date
MM
/
DD
/
YYYY
Instruction for human resources: please provide copy of the completed form to the employee and retain a copy in the employee file. Select the check box below to confirm that you read this instruction
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This form was created inside of Compassion North America Home Health Services.