Time Off Request Form
Filling out this form does NOT guarantee approval of time off. Please refer to the Time Off Request Policy in the Employee Handbook for more information. TIME OFF REQUESTS MUST BE SUBMITTED 2 WEEKS OR MORE IN ADVANCE OR IT WILL BE CONSIDERED A CALL OUT. ALL TIME OFF APPROVAL IS BASED UPON COVERAGE.
Time Off will be approved by the Personnel Coordinator.
DO NOT USE THIS FORM TO CALL OFF FROM A SHIFT! THIS IS FOR FUTURE VACATION REQUESTS ONLY! PLEASE CALL YOUR PERSONNEL COORDINATOR OR MANAGER IF YOU ARE CALLING OUT!
If you would like to request PTO or SICK time for days you have called out DO NOT USE THIS FORM! Please use the SICK and PTO request form! If you need a link to that form please contact
TODAY'S Date (date you are filling out this form)
Your First and Last Name
Individual you work with (the person you support)
Future dates you are requesting off at least 2 weeks in advance (please list month, Day and time of shifts)
Would you like to use PTO for these Days?
Yes! Please use my PTO
No, it will be UNPAID
Total number of PTO hours requested
A copy of your responses will be emailed to the address you provided.
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