Time Off Request Form

Information you will need

• What’s the employer’s name?
• What’s the employee’s name?
• What's the employee's ID number? (if applicable)
• What’s the employee’s department and position?
• How many days off are being requested?
• How many hours off are being requested?
• When would the requested time off begin?
• When would the requested time off finish?
• Is the employee requesting time off for a vacation?
• Is the employee requesting time off for personal leave?
• Is the employee requesting time off for sick leave?
• Is the employee requesting time off to vote?
• Is the employee requesting time off for family leave?
• Is the employee requesting time off for a funeral or bereavement?
• Is the employee requesting time off for jury duty?
• Is there an unlisted reason the employee is requesting time off?
• What other reason is time off requested for?
• Are there any additional comments?
• What’s the supervisor's name?
• Does the supervisor have any comments?
• Is time off approved?

Completed by the employee.

The form includes 2 signature lines.