Community Care Hospital
Benefits Request Form
* Required
Directions:
Make sure each section is complete. INCOMPLETE FORMS WILL NOT BE ACCEPTED.
When you finish the form press send on the bottom of the form so it will get sent to your supervisor and scheduling.
Vacation and Floating Holiday requests must be submitted at least 30 DAYS in Advance.
SUBMISSION OF A VACATION REQUEST DOES NOT GUARANTEE APPROVAL.
You will receive a response no later than 7 DAYS after the receipt of the Request. If you have not received a response, contact your supervisor.
BE SURE TO CHECK YOUR EMAIL OFTEN FOR RESPONSES.
What is your Full Name?
*
Your answer
What is your email address?
*
Your answer
Type of Benefit Days (List Hours Below) *Required
*
Vacation
Sick
Jury Duty
Holiday
Floating Holiday (Max of 8 Hours)
Military Leave
Leave w/o Pay
Bereavement
FMLA
Other:
Required
Total Number of Days being Requested
*
Choose
1 day
2 Days
3 Days
4 Days
5 Days
6 Days
7 Days
Day 1 Requested
*
MM
/
DD
/
YYYY
Day 2 Requested
MM
/
DD
/
YYYY
Day 3 Requested
MM
/
DD
/
YYYY
Day 4 Requested
MM
/
DD
/
YYYY
Day 5 Requested
MM
/
DD
/
YYYY
Day 6 Requested
MM
/
DD
/
YYYY
Day 7 Requested
MM
/
DD
/
YYYY
How many hours do I want to use?
*
Your answer
Do I have available time to take off? (CHECK PAY STUB 1st)
*
Yes
No (If no please be sure to schedule an appointment with your supervisor.)
Coverage Provided By: (Must be provided by an employee under the 80 hr threshold.)
*
Your answer
Comments
Your answer
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