EMPLOYEE TIME-OFF REQUEST FORM
Absence Information
Employee Name: ______________________________________________________________________________
Samantha Wall
Supervisor: _______________________________ Operator: __________________________________________
Taylor Pomerenk Joshua Kimzey
Type of Absence:
Vacation (144 hours or less) Extended Time Off (More than144 hours)* Time Off Without Pay
Military Service Sick FMLA Parental Leave Other
CATL (choose one: 1. Exposed at work OR Tested positive 2. Exposed outside of work OR symptoms with no Positive test)
Reason for Absence: (Optional) ___________________________________________________________________
Sick with fever and strep
____________________________________________________________________________________________
Start Date: _____________________________ Return to Work Date: _____________________________________
1/13 1/14
*For Extended Time Off Only: I acknowledge that I am responsible for working with my Department Head and/or
immediate supervisor to delegate all tasks and responsibilities prior to departure. Employee Initials: _______
Employee Signature: ___________________________________________ Date: ___________________________1/14/24
Supervisor Approval
Approved Denied • Comments: _____________________________________________
_________________________________________________________________________________________________
Supervisor Signature: ________________________________________ Date: __________________________
For Extended Time Off Only:
Department Head Signature (if different from above): _______________________________________________
Payroll Use Only
Check available vacation/sick balance • Copy to Human Resources
*If taking extended time off, please also complete the Application for Extended Time Off and give to your
Department Head and/or immediate supervisor.
