Construction Injury Leave of Absence Form
Request a leave of absence after a construction-related injury. Please complete all relevant sections below.
Employee Name
*
First Name
Last Name
Employee Email Address
*
example@example.com
Job Title or Department
*
Date of Injury
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Brief Description of Incident
*
Requested Leave Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expected Return Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Supervisor or Manager Name
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Employee Signature (Type your full name as acknowledgment)
*
Submit Leave Request
Should be Empty: