Bereavement Leave Request Form

Bereavement Leave Request Form
CPR recognizes the importance of taking time away from work following the loss of a loved one. Use this form to request bereavement leave in accordance with company policy.

Eligible family members include your spouse, parent, step-parent, child, foster child, daughter-in-law, son-in-law, sibling, grandparent, grandchild, or your spouse's parent, child, or sibling.

Your supervisor will review your request and may contact you if additional information is needed. Please refer to the Bereavement Leave Policy for complete eligibility requirements and leave provisions.

Please note: Submission of this form does not constitute approval. Employees should notify their supervisor as soon as practicable following the loss of a family member.
Today's Date

MonthDayYear
Date
Full Legal Name

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

MonthDayYear
Date
Are you FT or PT?
Who is your Bereavement leave for?
Is your Bereavement Leave continuous or intermittent?
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
Reason for denial:
Supervisor Signature
Should be Empty: