Time Off Request

Name*

First Last

Email*

Enter Email Confirm Email

Verify Dates Are Not Already Posted:*

If the dates you need off are already posted then you cannot fill out a time off request form. You will have to find someone to trade or cover your shifts and have the change approved by a shift leader or manager.

I have checked the schedule in Slack and the dates I am requesting are not already posted.

Is this request for days adjacent to a holiday?*

(Memorial Day, 4th of July, Labor Day, Thanksgiving, Christmas, or New Years)

Yes
No

If requesting off days adjacent to a holiday please only request the days leading up to the holiday OR the days after the holiday. You may not request off both before and after the holiday. Staff can request time off that includes a holiday twice per year. Requests for additional holidays may be declined and will be "back of the line" behind anyone who has not had 2 holidays.

Is your request compliant with the holiday policy?*

Yes
No

We will generally not make exceptions to the holiday policy, but you may explain and it will be considered.*

Are you requesting off a single day or multiple days in a row?*

Single Day
Multiple Days In A Row

Note: If you need to request multiple single days or sets of days in a row then you will need to fill out a new form for each separate request.

Date*

First day that you need to be off work:*

Last day that you need to be off work:*

Reason for time off request:

Documentation Required. Upload a jury duty summons. Alternatively you may turn in a printed copy of the summons.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.

Important Note: Full time employees must maintain 30 hours per week for full time status and benefits. If you need to use PTO to cover your request then it must be requested using the Payroll Adjustment Form during the payroll period that it needs to be paid. It cannot be requested in advance using this form.

Comments:

Captcha

Time off requests must be approved. You will receive a response by email. Please monitor your email and check your spam folder. If you have any questions you may contact Dr Stark via Slack.

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