For a vacation
1 or 2 weeks off
Complete 1-3 months in advance
This form is to request shifts off for a vacation. Do not use this form to ask time off for two or more periods, such as one vacation in July and another one in September. In this case, you will need to submit two separate forms.
To ensure that all of your assigned shifts are covered, you must complete this form requesting time off. Completing it does NOT mean that your request will be granted, because there is a number of things to consider before being able to give time off. If you have already made plans not to work, you may have to cancel them depending on whether your request will be granted.
Your Name ________________ Submission Date ___/___/___
When was the last time you had off? ___________ What was the reason? _______________________
How much notice are you giving for current request for time off? ________________________
What are the dates do you want off? Please, thinking about recovering time you may need afterward.
____/ ____/____ – ____/____/ ____ total number of shifts missed ________ total hours ________
OPTIONAL, Why are you wanting the above dates off? Please, be specific. ________________________________
_____________________________________________________________________________________
What shift(s) could you work to make up for your absence?
| Day of the week | Actual date | Shift time | Day of the week | Actual date | Shift time | |
TOTAL HOURS