S:\Human Resources\Forms HR\Time Off Request Form English-3.docx Maintained by Human Resources; Revised
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 average—see employee handbook)
4. PURPOSE (check all that apply):
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.
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):
Jury Duty or Witness Leave
(please attach summons)
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!
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
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: