Military Leave Notice Form

A form for employees to notify HR of military leave, provide order dates, and document benefits and reinstatement details under USERRA.

Employee Information

• Employee Name
• Employee ID
• Department
• Work Location
• Preferred Contact Email

Military Leave Details

• Type of Military Leave
• Leave Start Date
• Leave End Date
  If the end date is not yet known, leave this blank and update HR when available.
• Date Orders Were Received
• Anticipated Return-to-Work Notice Date
  If known, provide the date you expect to notify HR of your return-to-work availability.
• Brief Leave Reason or Assignment Summary

Orders and Documentation

• Upload Orders or Official Notice
• Are your orders or official notice available now?
• Do you need HR to follow up for documentation?
• Additional Notes for HR

Benefits and Pay Coordination

• Do you want HR to review benefits continuation during leave?
• Do you have payroll or leave balance questions?
• Specific Benefit or Payroll Concerns
• Preferred Contact Method for Benefits Follow-Up

Return to Work and Reinstatement

• Expected Return Date
• Will you need reinstatement support or schedule coordination?
• Known Return-to-Work Constraints
• Have you notified your supervisor?

Attestation and Consent

• Consent to Use Submitted Information for Leave Administration
  I understand that the information provided will be used by HR to administer my military leave, coordinate benefits and scheduling, and maintain an audit trail for leave processing.
• Attestation
  I certify that the information provided is accurate to the best of my knowledge and that I will notify HR if my leave dates or return-to-work plans change.