This request for time off form collects information about an employee's request including the type of time off being requested such as paid time off, sick leave, or comp time. It asks for the dates and number of days or hours being requested as well as space for any further explanation of the request. The employee signs and dates the form which is then passed to the supervisor who can approve, approve with modification, or unapprove the request with optional comments.

1. Request for Time Off
Name _______________________________________________________________________
Department __________________________________________________________________
REASON DATE(S) # OF DAYS # OF HOURS
Paid 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)
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Employee signature ______________________________________ Date
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SUPERVISOR’S RECOMMENDATION: COMMENTS:
Approved: ____________________________________
Approved with following modification: ____________________________________
Unapproved for following reason: ____________________________________
Supervisor’s signature ___________________________________ Date __________________
WHITE COPY: Supervisor YELLOW COPY: Staff Member