Jury Duty Leave Notice Form

Collects employee jury duty notice details, summons dates, pay coordination preferences, and return-to-work reinstatement information.

Employee Information

• Employee Name
• Employee ID
• Department
• Work Location

Jury Duty Summons Details

• Date Summons Was Received
• Court Name
• Court Location
• Jury Service Start Date
• Jury Service End Date
  If the end date is not yet known, leave this blank and provide the expected duration below.
• Expected Duration
• Upload Summons or Court Notice
  Upload only the summons page or notice page needed for HR verification.

Leave and Pay Coordination

• Requested Leave Start Date
• Requested Leave End Date
• Do you want to use available paid leave during jury duty?
• Pay Coordination Preference
  Choose how you would like pay to be coordinated if your policy allows multiple options.
• Other Pay Coordination Details
  Explain any special payroll or leave handling request.
• Expected Court Attendance Hours per Day

Work Coverage and Reinstatement

• Have you notified your supervisor?
• Coverage Notes
  Share any time-sensitive tasks or handoff notes that will help with coverage planning.
• Expected Return-to-Work Date
• Return-to-Work or Reinstatement Needs
• Additional Comments