Employee Time Off Request Sheet

Date: _________________           Employee: _______________________________________

I am requesting time off and would like to utilize it in the following manner:
(Please note consecutive days off as one entry.)
                    VACATION                                                           PERSONAL
Date _________________ Hour(s) _____            Date ___________________ Hour(s) ______
Date _________________ Hour(s) _____            Date ___________________ Hour(s) ______
Date _________________ Hour(s) _____            Date ___________________ Hour(s) ______

SICK

Date ___________________ Hour(s) ________
Date ___________________ Hour(s) ________
Date ___________________ Hour(s) ________

Other _____________ Please explain: _____________________________________________
          (Hours)

       ____________________________                     _________________________
      (Employee Signature)                                             (Date)
 ……………………………………………………………………………………………………………............……

_______ Approved
_______ Denied

       ____________________________                     _________________________
       (Department Head/Supervisor)                               (Date)

If denied, please state reason for denial: ______________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

NOTE: Official Staff time-off records are maintained in Human Resources. In the event that paid time off as approved is not available, time off will be applied against any available balances. Approved time off for staff who do not have any paid time available will be recorded as unpaid. Any unpaid time off is deducted from the next applicable paycheck.
…………………………………………………………………………………………………………………..............

HR OFFICE USE ONLY

Time off applied: _________ VAC / SICK / PERS

Unpaid: ___________

FML used during previous 12 mos. ________________________ Balance as of ____________________

OTHER (Explain) ________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________


Please maintain copies for: 1) Employee, 2) Supervisor.
Please send original to Human Resources.