Time Off Request
Please submit the times you request to take off work and the type of leave you are taking.
Professional Name (First, MI, Last)
Enter the last 4 numbers of your SS#
Type of leave requested
Sick leave (Illness or Injury)
Bereavement leave (Immediate Family)
Bereavement leave (Other)
Personal or Temporary leave without pay
Jury duty, Military duty or legal leave
Paid time off
Comments or Reason for leave
The first day you request to be off:
The last day you plan to be off:
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