Blank Time Off Request Form

Time Off Request Form
S:\Human Resources\Forms HR\Time Off Request Form English-3.docx Maintained by Human Resources; Revised
11/5/2012
Page 1
1. NAME (print): __________________________________ TODAY’S DATE: ____________
2. START Date: ___________ END Date: ______________ RETURN Date: __________
3. NUMBER OF HOURS I’m requesting off: ________________
(Note that paid hours may differ from requested hours due to your 14 week averagesee employee handbook)
4. PURPOSE (check all that apply):
VACATION
PERSONAL
SICK, NOT SERIOUS
Examples: routine medical/dental visits, flu,
common cold, routine headache, stomach
ache, sore throat
SICK, SERIOUS and/or FMLA/OFLA
(see reverse for definitions)
Must complete a Family and Medical Leave
Request form and attach it to this form.
OTHER:
Crime victim leave (ask Human Resources)
Domestic violence, sexual assault, or stalking victim leave (ask Human Resources)
Bereavement. Name of person, and relationship: _________________________________
5. CHARGE TO (check all that apply):
Vacation
Major Medical
Unpaid
Bereavement
Leave
Military leave (please attach orders, or forward as soon
as received)may be taken as unpaid, as per law
SIGNATURE OF EMPLOYEE
I understand that in almost all circumstances, I must obtain management approval before taking time off. I understand that
completing this form does not automatically constitute approval of my request for time off. I understand that unless the need for
leave is unforeseeable, it is my responsibility to discuss this arrangement with my supervisor prior to taking time off.
6. SIGNATURE: ___________________________________ DATE: ___________
Please return this form to your supervisor or, for Health Services, to Staffing. Thank you!
IMPORTANT INFORMATION
Complete form PRIOR to taking time off: at least 30 days for vacation and 2 weeks for personal leave.
If time off is UNFORESEEABLE, complete form:
o AT THE TIME OF REQUEST OR
o WITHIN 3 BUSINESS DAYS OF RETURNING TO WORK.
If time off is UNFORESEEABLE, attach an explanation to this form.
___Staffing/Sprvsr Dept. Head signature: __________________Date___ Approved Denied
ADDITIONAL AUTHORIZATIONS:
For FMLA/OFLA crime victim or domestic violence, etc.; or military leave only:
HR Director Approved Denied Signature: __________________ Date: _________
For Major Medical or unpaid Non/FMLA or OFLA extended personal leave of absence only:
Exec. Director Approved Denied Signature: __________________ Date: _________
Copy forwarded to payroll Copy returned to employee
Payroll use only (NOTE: where Items #3 or 5 and paid hours differ, provide copy of your changes to supervisor & ee):
14 week average Available hours:
Notes:
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