Retail Employee Burnout Leave of Absence Form
Request a leave of absence due to burnout. Please complete all sections to ensure your request is processed promptly.
Full Name
*
First Name
Last Name
Employee ID
*
Job Title
*
Store/Location
*
Supervisor/Manager Name
*
Contact Email Address
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please indicate the main reasons for your burnout (select all that apply):
*
Workload too high
Lack of support
Unpredictable schedule
Difficult customers
Insufficient breaks
Other
How would you rate your current level of burnout?
*
Not at all burned out
1
2
3
4
5
6
7
8
9
Extremely burned out
10
1 is Not at all burned out, 10 is Extremely burned out
Requested Start Date of Leave
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Requested End Date of Leave
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Comments (optional)
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employee Signature
*
Submit Leave Request
Submit Leave Request
Should be Empty: