Time Off Request Form
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1REQUEST FOR TIME OFF and/or PAID TIME OFF
Employee’s Name: _____________________________________________________
Date: ____________
Note: All absences are considered “Un-excused” if work is available, unless approved under Section # 1 or Section # 2 below. Requesting
Paid Time Off (PTO) benefits is addressed under Section # 3 below.
Section # 1
Requesting Time Off - Giving a Two Week Advance Notice
I am advising management that I will be off the following days, for the reason(s) indicated. No evidence/documentation is required, and if
this request does not conflict with other time off requests previously submitted and approved, this absence(s) will be considered as
“excused” and will not effect my eligibility for PTO at my next anniversary.
List Time Off
Indicate Reason(s)
______________________
__________________________________________________________________________________
______________________
__________________________________________________________________________________
______________________
__________________________________________________________________________________
Office Use Only
Yes
No
Was this request submitted within the two week (14 days) requirement? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “
“
Is there a conflict with time off previously requested by others? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “
“
Approved . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “
“
If not approved, give reason:______________________________________________________________________________
Signed:
Date:
Section # 2
Requesting Time Off - Under Emergency Option
I am requesting approval for time off under the “Emergency Option” available to me. This option requires some evidence/documentation
to support the “emergency” time off requested. If such evidence/documentation is not acceptable, this absence(s) will be counted as
“un-excused” and will effect my PTO eligibility at my next anniversary.
List Emergency Time Off
Reason for Time Off
Documentation Provided
_____________________ _____________________________________________
________________________________
_____________________ _____________________________________________
________________________________
Office Use Only
Yes
No
Was acceptable evidence/documentation submitted with this request? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “
“
Approved . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “
“
If not approved, give reason:______________________________________________________________________________
Signed:
Date:
Section # 3
Request for Paid Time Off (PTO) Benefits
“ I am NOT requesting any PTO benefits be paid to me regarding the time off requested in Section # 1 or Section # 2 above.
“ I am requesting ________ Hours of PTO benefits to be paid to me for the following reason:
“ Because of time off requested under Section # 1 above.
“ Due to lack of work.
“ Because of emergency time off requested under Section # 2 above.
“ Cash out benefits earned.
Office Use Only
Hours currently available: ________
Comment: ________________________________________________________
Hours approved:
________
Hours remaining:
________
Signed:
Date:
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