Fillable Printable Blank Time Off Request Form

Blank Time Off Request Form

Time Off Request Form

S:\Human Resources\Forms HR\Time Off Request Form English-3.docx Maintained by Human Resources; Revised

11/5/2012

Page 1

1. NAME (print): __________________________________ TODAY’S DATE: ____________

2. START Date: ___________ END Date: ______________ RETURN Date: __________

3. NUMBER OF HOURS I’m requesting off: ________________

(Note that paid hours may differ from requested hours due to your 14 week average—see employee handbook)

4. PURPOSE (check all that apply):

 VACATION

 PERSONAL

 SICK, NOT SERIOUS

Examples: routine medical/dental visits, flu,

common cold, routine headache, stomach

ache, sore throat

 SICK, SERIOUS and/or FMLA/OFLA

(see reverse for definitions)

Must complete a Family and Medical Leave

Request form and attach it to this form.

OTHER:

 Crime victim leave (ask Human Resources)

 Domestic violence, sexual assault, or stalking victim leave (ask Human Resources)

 Bereavement. Name of person, and relationship: _________________________________

5. CHARGE TO (check all that apply):

 Vacation

 Medical/Personal

 Major Medical

 Unpaid

 Bereavement

Leave

 Jury Duty or Witness Leave

(please attach summons)

 Military leave (please attach orders, or forward as soon

as received)—may be taken as unpaid, as per law

SIGNATURE OF EMPLOYEE

I understand that in almost all circumstances, I must obtain management approval before taking time off. I understand that

completing this form does not automatically constitute approval of my request for time off. I understand that unless the need for

leave is unforeseeable, it is my responsibility to discuss this arrangement with my supervisor prior to taking time off.

6. SIGNATURE: ___________________________________ DATE: ___________

Please return this form to your supervisor or, for Health Services, to Staffing. Thank you!

IMPORTANT INFORMATION

 Complete form PRIOR to taking time off: at least 30 days for vacation and 2 weeks for personal leave.

 If time off is UNFORESEEABLE, complete form:

o AT THE TIME OF REQUEST OR

o WITHIN 3 BUSINESS DAYS OF RETURNING TO WORK.

 If time off is UNFORESEEABLE, attach an explanation to this form.

___Staffing/Sprvsr Dept. Head signature: __________________Date___  Approved  Denied

ADDITIONAL AUTHORIZATIONS:

For FMLA/OFLA crime victim or domestic violence, etc.; or military leave only:

HR Director  Approved  Denied Signature: __________________ Date: _________

For Major Medical or unpaid Non/FMLA or OFLA extended personal leave of absence only:

Exec. Director  Approved  Denied Signature: __________________ Date: _________

 Copy forwarded to payroll  Copy returned to employee

Payroll use only (NOTE: where Items #3 or 5 and paid hours differ, provide copy of your changes to supervisor & ee):

14 week average Available hours:

Notes:

Time Off Request Form

S:\Human Resources\Forms HR\Time Off Request Form English-3.docx Maintained by Human Resources; Revised

11/5/2012

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OVERVIEW OF QUALIFIED FMLA OR OFLA LEAVE:

FMLA: A serious health condition under the FMLA means an illness, injury, impairment, or physical or mental condition that

includes at least one of the following:

Inpatient care in a hospital, hospice or residential medical-care facility, including any period of incapacity, or any subsequent

treatment in connection with such inpatient care; OR

Continuing treatment by a health care provider which includes one of the following:

 Incapacity due to a serious health condition lasting more than three (3) consecutive calendar days; and subsequent treatment

or incapacity relating to the same condition which includes either two or more treatments administered or supervised by a

health care provider, or at least one treatment with a continuing regimen of treatment;

 Incapacity due to pregnancy or absence for prenatal care;

 Incapacity or treatment thereof due to a chronic serious health condition, which requires periodic treatment by a health care

provider and continues over an extended period. (Incapacity may be episodic versus continuous, e.g., asthma, diabetes,

epilepsy, etc.),

 Incapacity which is permanent or long-term due to a condition for which treatment is not effective (e.g.; severe stroke,

Alzheimer’s, or the terminal stages of a disease); OR

 Absence to receive multiple treatments from a health care provider for restorative surgery and recovery therefrom, following

an injury or accident, or for a condition that would likely cause incapacity for at least three consecutive days if left untreated

(e.g. chemotherapy or radiation for cancer, physical therapy for arthritis, and dialysis for kidney diseases.)

Incapacity means inability to work or perform other daily activities due to treatment or recovery from a serious health condition.

Purpose of Leave: To care for your own serious health condition; a family member’s serious health condition; or following the

birth, adoption or foster placement of a child under age 18, unless incapable of self-care due to disability.

Military Family Leave Entitlements: Eligible employees with a spouse, son, daughter, or parent on active duty or call to active duty

status in the National Guard or Reserves in support of a contingency operation may use their 12-week leave entitlement to

address certain qualifying exigencies. Qualifying exigencies may include attending certain military events, arranging for

alternative childcare, addressing certain financial and legal arrangements, attending certain counseling sessions, and attending

post-deployment reintegration briefings.

Eligible employees may take up to 26 weeks of leave to care for a covered servicemember during a single 12-month period. A

covered servicemember is a current member of the Armed Forces, including a member of the National Guard or Reserves, who

has a serious injury or illness incurred in the line of duty on active duty that may render the servicemember medically unfit to

perform his or her duties for which the servicemember is undergoing medical treatment, recuperation, or therapy; or is in

outpatient status; or is on the temporary disability retired list.

Eligibility for Leave: You must have at least 12 months of employment with Friendsview; during your last 12 months of employment

prior to the leave request, you must have worked for at least 1,250 hours; AND leave must be for a qualifying

event.

Maximum Leave: 12 weeks in a 12-month period (measured backward from the date the employee uses any FMLA). If

Friendsview employs both parents, their combined parental leave is limited to the 12 weeks. Where applicable,

runs concurrently with OFLA leave.

OFLA: A serious health condition under OFLA means one of the following:

An illness, injury, impairment or physical or mental condition that requires inpatient care in a hospital, hospice or residential

medical care facility;

An illness, disease or condition that poses imminent danger of death, is terminal with a reasonable possibility of death in the

near future, or requires constant care; OR

Disability due to pregnancy or absence for prenatal care.

Purpose of Leave: Parental Leave: To care for your newborn, newly adopted or newly placed foster child who is under the age

of 18, unless incapable of self-care due to disability; Serious Health Condition Leave: To care for your own

serious health condition if it prevents you from performing at least one essential function of your job, or to care

for a family member’s serious health condition; Sick Child Leave: To care for your own child due to an

illness, injury or condition that is not a serious health condition, but requires home care.

Eligibility for Leave: For parental leave you must have been employed for at least the 180 days immediately preceding the start date

of the leave; for all other leave you must also have worked an average of at least 25 hours per week during the

180 days; AND leave must be for a qualifying event.

Maximum Leave: 12 weeks in a one-year period. An additional 12 weeks is available for a disabling illness, injury or condition

related to pregnancy or childbirth. An employee who takes the full 12 weeks of Parental Leave may also take 12

weeks of Sick Child Leave. Where applicable, runs concurrently with FMLA leave.