Employee Day Off Request Form printable pdf download

Employee Day Off Request Form

EMPLOYEE DAY OFF REQUEST FORM

Date submitted: _______ / _______ / _______

Employee Name: ___________________________________________________

Psychologist

(Last)

(First)

Therapist

As an employee submitting this form, I acknowledge that the policy of Senior Connections is to

accommodate my schedule request based on the needs of the clients, the therapy team, and as “first

come, first served.”

Date(s) Requested Off

First day off

Date:

_______ / _______ / _______

Last day off

Date:

_______ / _______ / _______

First day back to work

Date:

_______ / _______ / _______

__________________________________

Employee Signature

Psychologist Signature

Completed form must be submitted at least one (1) week prior to first date being requested off.

Fax form to 360-253-5170 or email to dross@seniorconnections.us

------------------------------------------------------------------------------------------------------------------------------------------

FOR OFFICE USE ONLY

For ALL Employees:

For Psychologist ONLY:

Date received:

______ / ______ / ______

Date logged:

______ / ______ / ______

Date Clinical Director notified:

______ / ______ / ______

Day Off Request, March 2015

Employee Day Off Request Form