MEDICAL LEAVE APPLICATION
[Your Company Name]
Please fill all required spaces in this Medical Leave Application form:
Employee Information:
Employee Name: | [Employee Name] |
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] |
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:
Supervisor Information
Supervisor Name: | [Supervisor Name] |
Position: | [Position] |
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] |
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.
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