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Request for Time Off
All Caregivers must submit requests for time off at least two weeks in advance by completing the time off request form either online or in the office
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* Indicates required question
Employee Name:
*
Your answer
Email:
*
Your answer
Last day working
*
MM
/
DD
/
YYYY
Day and Dates Requesting off (i.e.: Sat, June 1, Sun, June
*
Your answer
Two weeks notice prior to time off?
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Yes
No
Impacts all of your clients scheduled on the dates you are requesting off:
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Yes
No
If time off request does not impact all clients on the dates you are requesting off, please list the impacted clients here:
*
Your answer
Is a Caregiver schedule trade possible? (In other words, do you know of a Caregiver(s) who is/are willing to take some or all of your shifts during your time off and/or possibly trade shifts with you?)
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Yes
No
Not Sure
If you answered "yes" to the question above, please provide the names of the Caregiver(s) who might be willing to take some of your shifts?
*
Your answer
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