TIME OFF REQUEST

Name: ______________________________   Date of request: ____________
Role / location: ______________________________

Type of time off (check one):
[ ] Vacation or PTO
[ ] Sick
[ ] Personal
[ ] Unpaid
[ ] Other: ____________

First day off: ____________   Last day off: ____________
Partial day? [ ] No  [ ] Yes, from ______ to ______
Total hours requested: ______

Anything your manager should know? (You don't have to share medical details.)
______________________________________________________

Have you arranged cover for any scheduled shifts?
[ ] No shifts affected  [ ] Yes, with: ____________  [ ] Not yet

Employee signature: ____________________   Date: ____________

MANAGER USE ONLY
[ ] Approved   [ ] Approved with changes   [ ] Not approved
Notes: ______________________________________
Balance before: ______   Hours used: ______   Balance after: ______
Manager signature: ____________________   Date: ____________