APPLICATION FOR LEAVE OF ABSENCE
(For reasons OTHER than those covered by Leave for Family Care)
Head Teachers have authority to grant up to TWO days leave of absence
Requests for Leave for Family Care purposes MUST be submitted on the relevant application
form in accordance with the council’s Policy & Procedure which is available on MyToolkit
(https://www.westlothian.gov.uk/hr-services)
Details of how the council will process the personal information it holds on you can be found at
https://www.westlothian.gov.uk/media/20843/Contract-of-Employment---Privacy-Notice/pdf/2018-03-
21_-_Contract_of_Employment_Privacy_Notice.pdf
Name:
Post Title:
Work Location:
REASON FOR ABSENCE:
(Give as much information as possible in order that your application receives full consideration)
Total number of working days requested:
Date of first day of absence: Date of last day of absence:
Employee’s Signature: Date:
Please forward completed form to your Head Teacher who will consider your request and advise
you of the outcome by completing the page overleaf and returning a signed copy of the form to you
for your retention.
DATA LABEL: OFFICIAL - SENSITIVE
TO BE COMPLETED BY THE HEAD TEACHER
Outcome of request for leave of absence:
No. of days granted with pay: No. of days granted without pay:
If request refused please 3 box
REMARKS (i.e. reason for refusal):
I confirm the applicant has received a signed copy of this form in accordance with the guidelines.
Head Teacher’s Name (please PRINT):
Head Teacher’s Signature: Date:
For PAID leave of no more than TWO days, this form should be retained in school.
Where Leave of Absence Request is in Excess of Two Days, Head Teacher to forward
completed for to the Head of Service for Approval
Head of Service’s Signature: Date:
For UNPAID Leave or Leave in Excess of TWO Days, completed form must be returned to:
HR Services, Civic Centre, Howden South Road, Livingston EH54 6FF
For Human Resources Use Only
Application received date: Initials:
Application recorded date: Initials:
Copy form to Payroll (if LOA unpaid) date: Initials:
DATA LABEL: OFFICIAL - SENSITIVE
