This sample policy outlines a set of procedures for an industrial leave of absence, in accordance with all United States state and federal regulations pertaining to workers' compensation.

According to this sample, an industrial leave of absence should be granted based upon the needs of the employee as well as the needs of the company. In addition, an industrial leave of absence may be granted when an employee is injured or acquires an occupational illness while working at the company and is off work for fifteen calendar days or more. The employee is required to request the leave by submitting a leave of absence request form to his/her immediate supervisor and human resources.