Name

First Name

Last Name

Phone

(###)

###

####

Scheduled location

Requested day off start date

YYYY

Requested day off end date

If applicable

YYYY

Is this 10 days in advance?

If you are requesting days off less than 10 days in advanced you must also check in with a supervisor or manager to complete the process

Reason

For in-house clinics, what portion of the day do you need off?

Disclaimer

All requests must be submitted 10 days in advance, a request is not a guarantee of the time off being granted. If your requested date is inside of the 10-day advance notice period you are required to speak with your supervisor. If this day off request is approved, it will be changed to represent such in your schedule. If not, you will be expected to be at work as scheduled.

Day Off Request Form