Time Off Request Form
ADVERTISEMENT
1TIME-OFF REQUEST FORM
Fill in "Employee Section" and return to your Supervisor.
Requests should be made at least two (2) weeks prior to the date of absence, whenever possible.
.
EMPLOYEE SECTION
:
Employee's Name: ____________________________________________________________________________________
First Name - Please Print
Last Name - Please Print
Absence Information:
Dates of absence from work:
Starting On..................: _ _ / _ _ / _ _;
Departure Time (Only enter for partial days.).....: _ _ : _ _ am / pm
mm
dd
yy
circle one
I will return to work on: _ _ / _ _ / _ _;
Return Time(Only enter for partial days.)...........: _ _ : _ _ am / pm
mm
dd
yy
circle one
I am requesting time off for the following reason:
Jury Duty
Military Leave
Medical Leave (Short Term Disability)
Family Medical Leave Act (FMLA) (Official application forms are needed - See HR Dep't.)
__ for the birth and care of the newborn child of the employee
__ for placement with the employee of a son/daughter for adoption/foster care
__ to care for an immediate family member (spouse, child, or parent) with a serious health condition
__ to take medical leave when the employee is unable to work because of a serious health condition
Personal Leave __________________________________________________________________________________
Explain reason for absence of three days or more for personal reasons.
! Personal Emergency: I hereby certify that I missed work time on the above dates due to a personal emergency and the
nature & circumstance of my personal emergency was: __________________________________________________
_______________________________________________________________________________________________
Funeral/Bereavement _____________________________________________________________________________
Explain relationship to deceased.
Subpoenaed Court Appearance _____________________________________________________________________
Explain court case.
Other __________________________________________________________________________________________
Explain.
PAID (Deduct from my "PTO", if eligible)
UNPAID (Deduct from my "UTO", if eligible).
I would like my time-off to be:
• I understand that if my absence does not meet the criteria for an "Excused Absence" (as outlined in the Company
Handbook) my absence will be subject to attendance points (even if "scheduling approval" is obtained from my Foreman).
• I understand that if I'm not eligible for PTO, or if I've used up all my PTO, my absence will be UNPAID.
• I understand that I'm required to reserve PTO days to cover pay for "Company-Scheduled Plant-Closed Days".
_______________________________________________________________________________________________ Date: _ _ / _ _ / _ _
Employee Signature
mm
dd
yy
.
MANAGEMENT SECTION (Scheduling approval - based on work-load & staffing considerations.)
0
Approved Must Reschedule; Supervisor's Signature: ____________________________________________________
Approved Must Reschedule; Foreman's Signature (required): _____________________________________________
Remarks: ____________________________________________________________________________________________
____________________________________________________________________________________________________
Forward this form to the Human Resources Department.
"PTO" = Paid-Time-Off | "UTO" = Unpaid-Time-Off
C:1_S_&_PML25513(HR & Payroll)ml25513h1a2.doc | Revised: 27APR12 | Page 1 of 1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business