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Request for time off

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  • 1. Request for Time OffName _______________________________________________________________________Department __________________________________________________________________REASON DATE(S) # OF DAYS # OF HOURSPaid Time Off _______________ _________ __________Sick Leave _______________ _________ __________Comp Time _______________ _________ __________Annual Military Duty _______________ _________ __________Jury Duty _______________ _________ __________Death in Family _______________ _________ __________(specify relationship below)Other (explain below) _______________ _________ __________ TOTAL TIME OFF: _________ __________FURTHER EXPLANATION (when required)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Employee signature ______________________________________ Date _______________SUPERVISOR’S RECOMMENDATION: COMMENTS: Approved: ____________________________________ Approved with following modification: ____________________________________ Unapproved for following reason: ____________________________________Supervisor’s signature ___________________________________ Date __________________WHITE COPY: Supervisor YELLOW COPY: Staff Member