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.

Full time employees must maintain 30 hours per week for full time status and benefits. Please verify:*

Full time hours cannot be promised by moving shifts to a different day of the week. Sometimes that is not possible due to other people's schedules. It is important to have PTO available to cover requests if needed.

I have checked Dayforce to verify enough PTO hours to cover this request and maintain my full time status.
I am part time and do not need to maintain full time status.
I am taking approved paid CE time.
I am requesting a medical, maternity, or other extended leave of absence.

Comments:

Important Note: If you need to request PTO then you must request it on the payroll period that you want to receive it. PTO is requested using the Payroll Adjustment Form (same form you use to correct your timecard).

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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