Time-Off Request Form

Employee time-off / PTO request — dates, leave type, manager approval signature.

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TIME-OFF REQUEST

Employee:       Sam Rivera
Employee ID:    EMP-04217
Department:     Engineering
Manager:        Pat Chen
Request date:   May 23, 2026

──────────────────────────────────────────────────────────────────────

LEAVE DETAILS

Leave type:     PTO
Start date:     __________________
End date:       __________________
Business days:  5

Reason:
Pre-planned family vacation.

Coverage / handoff plan:
On-call rotation covered by Jordan (already swapped). Open PRs reassigned to Alex. Slack auto-responder set; emergencies routed via PagerDuty as usual.

Emergency contact during leave:
Mobile (555) 010-7788, urgent only

──────────────────────────────────────────────────────────────────────

EMPLOYEE CERTIFICATION

I certify that the information above is accurate. I understand that
unapproved absence may be subject to disciplinary action under company
policy.

Employee signature: ____________________________   Date: ______________

──────────────────────────────────────────────────────────────────────

MANAGER APPROVAL

[ ] Approved              [ ] Denied              [ ] Approved with changes

Manager comments:
__________________________________________________________________

Manager signature: ____________________________   Date: ______________

──────────────────────────────────────────────────────────────────────

HR USE ONLY

PTO balance before:    _________      PTO balance after:    _________
Recorded by:           ____________________________   Date: ______________

About this template

A time-off request form is the standard paper trail that makes attendance auditable for both employer and employee. The form captures: who is leaving, when, for how long, what kind of leave, and who approved it. For FMLA-qualifying leave, additional medical certification (DOL Form WH-380-E or WH-380-F) is required separately; this form just initiates the request. For state paid-sick or paid-family leave (CA, NY, NJ, MA, WA, CT, OR, CO), the request triggers the employer's separate filing with the state PFML agency. Many companies maintain leave balances in HRIS (Workday, BambooHR, ADP) — the form is the source-of-truth document.

When to use it

  • Pre-planned PTO / vacation (request typically 2 weeks ahead per most policies)
  • Sick leave when used after the absence (formal "make-up" paperwork)
  • FMLA / state paid family leave — pairs with the medical certification form
  • Unpaid leave or sabbatical request

What to include

  • Employee name + ID + department + manager
  • Request date (when submitted)
  • Leave type from a defined picklist
  • Start + end dates + business-day count
  • Reason (free-text; required for FMLA/medical, optional for PTO)
  • Coverage / handoff plan — specific names not generic "team will cover"
  • Emergency contact during leave
  • Employee + manager signature lines
  • HR PTO-balance tracking section

Frequently asked

Default to your company handbook. Common conventions: PTO/vacation 2 weeks for ≤ 1 week off, 30 days for ≥ 2 weeks off, 90 days for sabbatical. Sick: same-day notification (no advance form). FMLA: 30 days for foreseeable leave (29 CFR §825.302); for unforeseeable, "as soon as practicable" usually means same business day.
⚠ Legal disclaimer. This template is provided for informational purposes only and is not a substitute for legal advice from a qualified attorney. Always consult a licensed professional before using this document for any binding agreement.
Jurisdiction: United States — FMLA 29 USC §2601+ (qualifying unpaid leave, 12 weeks/yr); state paid sick-leave laws (CA Lab. Code §246; NY Lab. Law §196-b; WA RCW §49.46.210; +14 other states); state paid-family-leave programs (CA SDI/PFL, NY PFL, NJ FLI, MA PFML, WA PFML, CT PFML, OR PLO, CO FAMLI). ADA (42 USC §12112) leave-as-reasonable-accommodation. Employer-specific PTO/sick/vacation policies layered above statutory floor.
Last reviewed: 2026-05
Reviewed by ScoutMyTool — consult a licensed attorney for binding use.

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