TIME OFF REQUEST FORM
FACILITY: _________________________
DATE: _______________
EMPLOYEE NAME: __________________________________________
REASON FOR REQUEST: _________________________________________ _______________________________________________________ _______________________________________________________ DATES REQUESTED: START: __________ END:__________ BACK TO WORK ON: ____________
UNPAID TIME REQUESTED:
_________ DAYS _________ HOURS
VACATION TIME REQUESTED: _________ DAYS _________ HOURS
____________________________________ ADMINISTRATOR’S APPROVAL
____________________________________ PRESIDENT’S APPROVAL