Free Medical Leave Application HR Template
MEDICAL LEAVE APPLICATION
[Your Company Name]
Please fill all required spaces in this Medical Leave Application form:
Employee Information:
|
Employee Name: |
[Employee Name] |
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Position: |
[Position] |
|
Department: |
[Department] |
|
Employee ID: |
[Employee ID] |
|
Contact No.: |
[Contact Number] |
|
Email Address: |
[Email Address] |
Leave Details:
|
Type of Leave: |
Medical Leave |
|
Start Date: |
[Start Date] |
|
End Date: |
[End Date] |
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Total Days: |
[Total Number of Days] |
|
Reason for Leave: |
[Reason for Medical Leave] |
Medical Documentation
Attach medical certificates, doctor's notes, or any relevant documentation.
File Attached:
-
Yes
-
No
Supervisor Information
|
Supervisor Name: |
[Supervisor Name] |
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Position: |
[Position] |
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Contact No.: |
[Contact Number] |
|
Email Address: |
[Email Address] |
Employee Declaration
I, [Employee Name], hereby declare that the information provided above is accurate and true to the best of my knowledge. I understand that false information may lead to termination of employment or other disciplinary action.
Signature: [Signature]
Date: [Date]
For HR Department Use Only
|
Application Status: |
|
|
Reviewed By: |
[HR Representative Name] |
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Date Reviewed: |
[Date Reviewed] |
|
Comments: |
[HR Comments] |
Please submit this completed form along with any necessary medical documentation to the HR Department. For any questions or clarification, contact [HR Contact Details].
This form is in accordance with company policy and adheres to state and federal laws regarding medical leave.
