Name *

First Name

Last Name

Check to Confirm: *

PLEASE CHECK THE TIME OFF QUEUE LINK (above) BEFORE REQUESTING TIME OFF. If someone else has already been approved for those dates, your time off will NOT be approved. Additionally, there may be black out dates where no time off will be considered. Time off is limited, as all shifts must be covered! Please don’t assume time off is approved unless you receive an approval email. To guarantee time off, you’re welcome to find coverage ahead of time and note that in this form.

I have checked the Time off Queue

Early-Out or Late-In Time - IF APPLICABLE

Hour

Minute

Second

AM PM

Starting Date of Absence *

MM

DD

YYYY

Ending Date of Absence *

MM

DD

YYYY

Return Date *

MM

DD

YYYY