"Time off Request Form - Aoi Home Care"

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Download "Time off Request Form - Aoi Home Care"

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Time Off Request Form
Requests should be submitted to your scheduler via email, fax, or mail.
Employee Name____________________________________________________________________________________
(Please Print)
: _______________________________
_____________________________________
Dates Requesting Off
thru
(Month/Day/Year)
(Month/Day/Year)
_______________________________
I will return to work on:
(Month/Day/Year)
____My client(s) will not need another aide to cover these visits.
____My client(s) will need another aide to cover these visits.
Reason for request:
__________________________________________________________________________________________________
Total amount of hours requested off:
(Please enter “0” if you prefer NOT to be paid for this time off)
PTO________________
Vacation________________
Sick________________
Employee Signature ____________________________________________
Date____________________________
__________________________________________________________________________________________________
Administrative Use Only:
☐ Approved
☐ Denied
Initials: _________
Pay Date(s)
PTO Hours
Vacation Hours
Sick Hours
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
Notes:
Revised 6/6/2017
Time Off Request Form
Requests should be submitted to your scheduler via email, fax, or mail.
Employee Name____________________________________________________________________________________
(Please Print)
: _______________________________
_____________________________________
Dates Requesting Off
thru
(Month/Day/Year)
(Month/Day/Year)
_______________________________
I will return to work on:
(Month/Day/Year)
____My client(s) will not need another aide to cover these visits.
____My client(s) will need another aide to cover these visits.
Reason for request:
__________________________________________________________________________________________________
Total amount of hours requested off:
(Please enter “0” if you prefer NOT to be paid for this time off)
PTO________________
Vacation________________
Sick________________
Employee Signature ____________________________________________
Date____________________________
__________________________________________________________________________________________________
Administrative Use Only:
☐ Approved
☐ Denied
Initials: _________
Pay Date(s)
PTO Hours
Vacation Hours
Sick Hours
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
Notes:
Revised 6/6/2017