Request for Time Off - July 1, 2023

Please use this to request time off if you will be absent during your regular work hours.

Are You a Full-Time (20+ hours/week) or Part-Time Employee? *
Name *
Part-Time Employee Name *
Email *
What Category of Time Off are you Requesting? *

Page numbers refer to July 1, 2023 Employee Handbook.
If Other, Please Explain *
How many full days are you requesting to be absent from your job?
Date of requested absence Date of requested absence * / MM / DD YYYY
First date of requested absence First date of requested absence * / MM / DD YYYY
Last date of requested absence Last date of requested absence * / MM / DD YYYY
How many hours are you requesting to be absent from your job, if less than a full day?
Must be a number between 1 and 7
Date of requested absence Date of requested absence * / MM / DD YYYY
Start time of requested absence Start time of requested absence * : HH MM AM/PM
End time of requested absence End time of requested absence * : HH MM AM/PM
How will your work areas be covered in your absence? *
Do you anticipate that other employees will need to adjust their hours or schedule to accomodate your absence? *

Do you anticipate that other employees will need to adjust their hours or schedule to accomodate your absence? Yes No
If yes, please explain *
Notes/Comments
Is this request due to a medical issue that qualifies under the Family and Medical Leave Act? *

Is this request due to a medical issue that qualifies under the Family and Medical Leave Act? Yes No
If yes, please indicate when a good time would be to discuss this issue in detail.
Manager's Approval
.
.

________________________________________

Request for Time Off - July 1, 2023

Request for Time Off - July 1, 2023

Manager's Approval . .

Manager's Approval
.
.