Leave Application Form

Version No: 33 | Author: BPL – Human Resources

Name: A workplace incident/injury has occurred and is
recorded in SolvSafety. I would like to be paid from my
Position: leave accruals. I understand that should I make claim for
workers’ compensation and it is accepted by the Insurer my
Facility/Area: leave accruals will be reimbursed.
No of
No of No. Public Date of Leave Date of Leave Actual Date
working Type of Leave (Circle)
weeks holidays Commences Completion Return
days
Annual
Personal (Sick/Carers)
Parental Leave
Leave without pay
Other, specify

Medical Certificate attached: Yes / No / Not applicable

A Medical Certificate is required for the following. If requesting planned sick leave or parental leave an appropriate
medical certificate is required.
1. Sick leave after two consecutive days sick 4. Parental Leave (Please refer to your relevant EA)
(please refer to your relevant EA or the HTG for
more confirmation)
2. Food handlers under new regulations 5. Where a workplace incident/injury has occurred.
3. A family member who is sick or seriously ill after NOTE: If a claim for workers’ compensation is made, any paid
leave taken in relation to the incident/injury will be reimbursed
two consecutive days IF the claim is accepted by the Insurer

COMPLETE THIS SECTION FOR ALL LEAVE

Shift Times Total Shift Times Total
Date Day Date Day
Start Finish Hours Start Finish Hours
Monday Monday
Tuesday Tuesday
Wednesday Wednesday
Thursday Thursday
Friday Friday
Saturday Saturday
Sunday Sunday

Shift Times Total Shift Times Total

Date Day Date Day
Start Finish Hours Start Finish Hours
Monday Monday
Tuesday Tuesday
Wednesday Wednesday
Thursday Thursday
Friday Friday
Saturday Saturday
Sunday Sunday
APPROVAL ADVICE
Please pay my salary: { } fortnightly as usual { } in the pay before leave starts

Employee Signature: ___________________________________Date: ___________________________________

Approved: YES / NO (please circle)

Facility Manager / Manager Signature: ____________________Date: ___________________________________