Time Off Form Name* First Last This form must be submitted at least two weeks prior to the requested time off to be considered for approval. There may be times when, even with adequate notice, requested time off will not be granted due to program needs or work coverage. If you will be taking time off due to a scheduled medical procedure, please fill this form out as far in advance as possible. This form should be turned in to your supervisor.Time Off Request*PaidUnpaidIf Paid:* PTO Paid Sick Time Reason For Time Off* Time Off Requested* Partial Day One-Half (1/2) Day One Day Multiple Days Date/Total HoursDate Date From Through Direct Care Shifts Needing CoverageConsumerDate Time : HH MM AM PM Coverage Not Needed By Family Would You Like To Add Another Shift Needing Coverage?YesNoConsumerDate Time : HH MM AM PM Coverage Not Needed By Family Would You Like To Add A Second Shift Needing Coverage?YesNoConsumerDate Time : HH MM AM PM Coverage Not Needed By Family Would You Like To Add A Third Shift Needing Coverage?YesNoConsumerDate Time : HH MM AM PM Coverage Not Needed By Family Would You Like To Add A Fourth Shift Needing Coverage?YesNoConsumerDate Time : HH MM AM PM Coverage Not Needed By Family Would You Like To Add A Fifth Shift Needing Coverage?YesNoConsumerDate Time : HH MM AM PM Coverage Not Needed By Family Would You Like To Add A Sixth Shift Needing Coverage?YesNoConsumerDate Time : HH MM AM PM Coverage Not Needed By Family Would You Like To Add A Seventh Shift Needing Coverage?YesNoConsumerDate Time : HH MM AM PM Coverage Not Needed By Family Would You Like To Add An Eight Shift Needing Coverage?YesNoConsumerDate Time : HH MM AM PM Coverage Not Needed By Family * I agree that the information above is correct. Date Submitted* MM DD YYYY *Employees will be paid only for time accrued. Approval for time off does not mean employees will be paid if they do not have enough hours.
