Temporary Time Off Request

This form must be completed by the employee, approved by a supervisor, and submitted to the personnel office 14 days prior to the requested time off. Please specify below whether the time off requested is paid or unpaid, and list the exact days you are requesting, including the day of the week and date. Carefully read each section for your benefit.

Name

Employee #

Please make a selection.

Options

Paid Time Off Unpaid Time Off

Scheduled Appointment Date

Scheduled Appointment Time

Reason

Scheduled Appointment Date

Scheduled Appointment Time

Reason

Scheduled Appointment Date

Scheduled Appointment Time

Reason for Time Off

Please make a selection.

Select One

Acknowledgment

Acknowledgment of Time Off Conditions

I understand that the requested time off (paid or unpaid) will only be granted if my job site is adequately staffed during the requested period. Management reserves the right to modify this request within a reasonable time frame due to emergencies.

Name

Today's Date