COVID-19 Leave Request Form

A form employees use to request COVID-19-related leave, specifying the reason, dates, and whether they will be available for remote work.

Use this template

Name

Nombre

Apellido

Email

Phone Number

Department

Position

Supervisor Name

Nombre

Apellido

Request leave due to:

Illness Quarantine Caregiving Other

Leave Starting Date

Leave End Date

Will you be available for online work?

Yes No

Supporting Documents / Sick Report

Max 10 MB per file

Additional Comments

Date

Signature

Sign here

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