Jury Duty Leave Notice Form

Form for employees to notify HR and management of jury duty summons dates, pay coordination, and return-to-work reinstatement details.

Employee Information

• Employee Name
• Employee ID
• Department
• Manager Name

Jury Duty Summons Details

• Date Summons Was Received
• Court Name
• Jury Service Start Date
• Jury Service End Date
• Upload Jury Summons
  Optional. Upload a copy of your summons if available. Do not include unrelated personal documents.

Leave and Work Schedule

• Will you be absent for full workdays during jury service?
• Expected Schedule Impact
  Select all that apply based on your current summons information.
• Coverage Notes for Manager
  Optional. Share only work coverage details needed for scheduling. Do not include sensitive personal information.

Pay Coordination

• Do you need pay coordination for jury duty time?
• Preferred Pay Coordination
• Upload Jury Pay Documentation
  Optional. Upload any court-issued pay documentation or proof of attendance if available.

Return to Work and Reinstatement

• Expected Return-to-Work Date
• Do you need reinstatement or schedule restoration support?
• Reinstatement Notes
  Optional. Describe any return-to-work concerns, schedule changes, or documentation HR should review.