Time Off Request

Employee Name:  Phone Number: Date of Birth:  
Patient Name(s): 
Personal Time Off / Vacation: 

Start Date: 
   Return to work Date: 


Please note: You must provide a minimum of 2 week notice for it to be eligible for PTO.
You may not use less than 4 hours of PTO each day.

Sick Time:

Start Date: 
 Return to work Date:   

Please Check : 
 certify that this requested sick leave will be used for an authorized use under the Law and the Rules. (For more details on authorized uses refer to the company handbook)
Permanently Off Case:

Last date to work: 

Please Check :

My last date of work will be in less than 2 weeks. Please provide a reason of why 2-week notice was not provided: 
Safe Leave:

Start date : 
      Return to work date: 

Please attach reasonable documentation for this leave. The time will not be approved without documentation.
Employee Signature:                                                                                                                       Date :