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)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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