Time Off Request - Fillable Online Form

Caregiver's Time Off Request - Fillable Online Form

Employee Name*

First NameLast Name

E-mail*

Time Off requests are subject to administrative approval. Please submit the Time Off request in writing 30 days prior to the requested time off (Unplanned medical and other emergent requests are exceptions). This enables HHH to try to provide alternative staffing coverage for clients / families.

If more than one request is made for the same client in the same week every effort will be made to grant both requests, but this cannot be promised. If adequate staffing cannot be found, the first request received will be granted. For major holidays we ask that requests not be made more than 90 days in advance.

Note, per PTO Policy, if you are FT or PT and you don't request enough PTO, Payroll will draw enough PTO to maintain a bi-weekly average of your FT / PT classification.

First day Requested*

MonthDayYear

Last day Requested *

MonthDayYear

Number of PTO or EPL Hours Requested:*

Additional Information:

Signature *