Time Off Request Form Fields

  • Employee Name:

  • Employee #:

  • Time Off Start Date:

  • Time Off End Date:

  • Total Number Of Days Off Work:

  • Please Indicate The Type & Total Days Below:

  • Field Employees are Entitled to 3 unpaid Personal Days After Completion of 1 Year of Service. More Than 2 Personal Days Requires 2 Weeks Notice.

  • Personal Days:

  • Field Employees are Earn 5 Vacation Days At The Start of Their 11th Year of Service. Personal Days Are Not Available to Employees if They Have Earned Vacation. Vacation Days Require 3 Weeks Notice.

  • Vacation Days:

  • See Employee Handbook for terms and Conditions of Paid and Unpaid Funeral Leave.

  • Funeral Leave:

  • Time Off for Doctor or Dental Visits, FMLA, or any special Request Not Including Personal Days While Available to Employee.

  • Other Time Off:

  • Employee Signature & Date:

  • Foreman's Signature & Date:

  • Operation's Manager Signature:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. Any ratings or scores displayed in our Public Library have not been verified by SafetyCulture for accuracy. Users of our platform may provide a rating or score that is incorrect or misleading. You should independently determine whether the template is suitable for your circumstances. You can use our Public Library to search based on criteria such as industry and subject matter. Search results are based on their relevance to your search and other criteria. We may feature checklists based on subject matters we think may be of interest to our customers.