DeSo Time Off Request Form
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This document is a time off request form for an employee at DeSo Hair Bar. It requests the employee's name, location, position, type of absence, dates of absence, and reason for time off. The employee must sign acknowledging absences are subject to approval. The manager will then sign approving or rejecting the request and can add any comments.
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NameofResponsiblePerson Relationship Phone PT.docx
Name of Responsible Person: Relationship: Phone: PT/CL Name: Date:
Address:
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Prior Medical Social Work Service Referral Source/Date
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________________________________________________________________________________________________________
________________________________________________________________________________________________________
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(names and relationships) (names and relationships)
________________________________________________________________________________________________________
________________________________________________________________________________________________________
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Key PT = Patient
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PT PCP PT PCP PT PCP
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Memory
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Judgement/Decision Making
Communciation Ability
Knowledge of Health Problems
Motivation to Resolve Needs
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Client/Designee: I certify that the Matrix Home Cae Employee
listed on this time slip worked the times indicated and the owrk was
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this time slip.
Employee Signature: _________________________________
Patient/Client Signature: ______________________________
PT/CL NAME: _____________________________________
ADDRESS: _______________________________________
CITY, STATE, ZIP: __________________________________
VISIT
DATE: ____________________________________________
TIME IN:__________________ TIME OUT: ______________
10/09/12 Medical Social Work Assessment Page 1 of 2
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DeSo Time Off Request Form
- 1. DeSo Hair Bar Time off Request Time Off Request Employee Name: Location: Position: Type of Absence Requested: Personal Vacation Bereavement Sick Time Off to Vote Jury Duty Maternity/Paternity Other Dates of Absence: From: To: I understand that time away from work is subject to management approval and firm polices. Reason for Time Off: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ You must submit requests for absences, other than sick leave, two weeks prior to the first day you will be absent. Employee Signature Date Manager Approval Approved Rejected Comments:_________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Manager Signature Date