TIME OFF REQUEST FORM for Accra/Consumer Choice, Inc.
You are eligible for Paid Time Off (PTO) if:
You have worked 600 hours after July 1, 2015.
Have accrued eligible PTO hours; you will earn 1 PTO hour for every 52 hours worked beginning July 1, 2015.
Your PTO balance is available on your ADP Paystub.
The Participant/Responsible Party has approved to your use of PTO.
You may use PTO hours when the participant is hospitalized.
Refer to the Paid Time Off policy for more information regarding eligibility.
Name (print): ___________________________________ EmpID: ____________
Date: _____________________
REQUEST FOR PAID TIME OFF
Start Date: ___________
End Date: ______________
Total Hours Requested: ___________
Comments: _______________________________________________________________________________________________________
I am requesting to use _____ hours of PTO while the participant is in the hospital. Signature of the Participant/RP is not required.
I am requesting to be paid for ____ hours of PTO.
________________________________ __________
___________________________ __________
Employee Signature:
Date:
Participant/RP Signature
Date
Signature by the Participant/RP indicates approval of PTO – Participant/RP is responsible for securing replacement care.
Approval by Employee and the Participant/RP does not guarantee payment of time off.
This PTO form must be submitted with your timecard for the period in which you are requesting PTO.
________________________________________________________________________________________________________________
Internal use only – to be completed by employee services at Accra:
_____ APPROVED _____DENIED ___ No Paid Time Available ___ Other _________________________ Initials of Accra staff: _____