Bereavement Leave Request Form

Bereavement Leave Request Form

Qualifications: your spouse, your parent and/or step-parent, your child and/or foster child, your daughter-in-law or son-in-law, your sibling, your grandparent, your grandchild, your spouse's parent, child, and/or sibling.
Full Legal Name*

First NameLast Name
CPR Email Address*
example@example.com
What was your hire date?*

MonthDayYear
Date
Are you FT or PT?*

Full-time benefit eligible (35+ hours)Part-time benefit eligible (30-34 hours)Part-time not benefit eligible (29 hours or less)
Who is your Bereavement leave for?*
Is your Bereavement Leave continuous or intermittent?*

ContinuousIntermittent
What is your expected Bereavement Leave start date?*

MonthDayYear
Date
When is your expected return to work date?*

MonthDayYear
Date
Intermittent Bereavement Dates and Notes:*
Please note: After submitting the bereavement leave request form, it will be marked as pending.

Once your supervisor approves it, you will receive an email with tentative approval and a link to upload the required documentation (e.g., death certificate, obituary, funeral program).

Your leave will be officially approved once we have received all necessary documents. To ensure your timecard is accurate and that you are paid correctly, please provide the relevant documents promptly.
Supervisor's Full Legal Name*

First NameLast Name
Supervisor's CPR Email Address*
example@example.com
Supervisor's Status*

ApprovedDenied
Reason for denial:*
Supervisor Signature*

Clear
Should be Empty: