Time Off Request Form - Aoi Home Care printable pdf download

Time Off Request Form - Aoi Home Care

Time Off Request Form

Requests should be submitted to your scheduler via email, fax, or mail.

Employee Name____________________________________________________________________________________

(Please Print)

: _______________________________

_____________________________________

Dates Requesting Off

thru

(Month/Day/Year)

_______________________________

I will return to work on:

(Month/Day/Year)

____My client(s) will not need another aide to cover these visits.

____My client(s) will need another aide to cover these visits.

Reason for request:

__________________________________________________________________________________________________

Total amount of hours requested off:

(Please enter “0” if you prefer NOT to be paid for this time off)

PTO________________

Vacation________________

Sick________________

Employee Signature ____________________________________________

Date____________________________

__________________________________________________________________________________________________

Administrative Use Only:

☐ Approved

☐ Denied

Initials: _________

Pay Date(s)

PTO Hours

Vacation Hours

Sick Hours

_______________

Notes:

Revised 6/6/2017

Time Off Request Form - Aoi Home Care