Leave Request Form

(Leave is officially granted only when the employee received a copy of this form with the approval of his/her
supervisor and the Admin Manager indicated by signature and date. Please request annual leave at least 5 working
days in advance)

Employee’s Name: ________________________ Leave requested from: ________/________/________

Employee’s Title: _________________________ Leave requested to: _________/________/________

ID Code #:____________ Total # of Days Requested: ____________

TYPE OF LEAVE (account for total days requested below):

Annual Leave: ________________

Sick Leave: ________________
Other (Explain): __________________________________________________

Total days:

Employee who will cover during your absence: ___________________________________________

In case of emergency, Address/Telephone number where you can be reached:

____________________________________________________________________________________

Employee’s Signature: _____________________________ Dated: ______________________

DO NOT WRITE BELOW (For HR Use only)

Annual Sick Others

Number of leave days availed: ___________ ____________ _______________

Number of leave days remaining: ___________ ____________ _______________

Prepared/Checked By:

Name: _________________________ Sign: _____________________ Date: _______________________

Note: _________________________________________________________________________________

Supervisor’s Approval/Comments: _______________________________________________________________

Received By HR Department: _______________________________________

Approved By Hospital Director: ‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬