Community Living Alliance Time Off Form printable pdf download

Community Living Alliance Time Off Form

For Office Use Only

Approved

Denied

Reason for Denial _______________________________________

Date Employee Notified of Denial _________________________

Community Living Alliance Time Off Form

PLEASE NOTE:

All planned time off requests require 2-week notice. All unplanned time off requests must be turned in with Record of Cares

for the week in which you missed the shift. Failure to complete this form may jeopardize your benefit eligibility and approval

of time off. PCWs potentially have up to 30 calendar days of Planned or Unplanned Absences per calendar year.

INSTRUCTIONS:

Please print clearly in blue or black ink. Complete BOTH sides of the form and sign on back.

PCW’s Name: ___________________________

PCW’s Phone Number: ____________________________

First Date off: ____________________________ Expected Return Date: _____________________________

Please list all the clients who will be affected by this time off:

Do you carry any insurance from CLA?

Yes

Please complete the appropriate section below to indicate WHY you are requesting off or missed work.

Medical Related Absence

Planned / Unplanned Absence

Client Not Available

Reason

Client Name

Is the Medical Condition for:

____________________________

Yourself

____________________________

Spouse/Domestic Partner

____________________________

Reason Client is Unavailable

Your Child

____________________________

Your Parent

____________________________

Your Military Serving

____________________________

Family Member

Will you travel outside the USA?

____________________________

Yes

Are you available for temporary

**Human Resources will follow

hours while Client is unavailable?

up with additional paperwork.**

If yes, country: _______________

Yes

Have you notified your client?

If no, why?

Yes

____________________________

PLEASE COMPLETE & SIGN THE BACK OF FORM

Community Living Alliance Time Off Form

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