Time OFF Request Time Off Requests Employee Name(Required) First Last Employee Email(Required) Enter Email Confirm Email Staff or Clinician?(Required)StaffClinicianToday's Date (Date of Request)(Required) MM slash DD slash YYYY Is this request at least 6 weeks in advance?(Required)YesNoTime away from work must be submitted in 6 weeks in advance wherever possible, except in the case of emergencies or incidental requests which could not be avoided. Please indicate the emergency or incident which prevented you from providing 6-weeks notice.(Required)Time Off Beginning Date(Required) MM slash DD slash YYYY Time Off Ending Date(Same Day if Only Requesting 1-Day Off)(Required) MM slash DD slash YYYY Amount of Time Off Requested(Required)1 hour2 hours3 hours4 hours0.5 days1 day2 days3 days4 days5 days6 days7 days8 days9 days10 daysLonger than 10 daysSpecify Amount of Time Off Requested(Required)Please enter a number from 11 to 20.Number of Client Days Off Requested(Required)Please enter a number from 0.5 to 8.Are you using paid time off or unpaid time off?(Required)Paid Time OffUnpaid Time OffPlease enter the date(s) you will be using as Make-Up Days. (NOTE: The eligible time frame for make-up days is the same Sunday to Saturday in which your intended time off takes place. For example, if you normally work MWF and take off a Friday, your make-up day should occur the preceding Sunday, Tuesday, Thursday, or Saturday of the same week.)(Required)Attestation Regarding Employment Agreement & Handbook(Required) I reiterate my understanding of the below language included on my employment agreement and in the employee handbook.1. In advance of time away from work, clinicians are generally expected to shift as many appointments as possible to other days of the same business week so as not to incur substantial financial loss for Change, Inc. or themselves. 2. Time away from work must be submitted in 6 weeks in advance wherever possible, except in the case of emergencies or incidental requests which could not be avoided. 3. Change, Inc. reserves the right to request that time away not occur on certain dates, even within the limits of the specified number of allowable/available days off, particularly when time-off is to occur during a week where others are already expected to be away. Attestation Regarding Scheduling Support(Required) I understand and agree to the below additional items which allow clinicians to access support and accountability regarding scheduling protocol within the environment.1. Once my time off is approved AND if I am required/doing a make-up day(s), I will email the appropriate ACD (nicole@changeincorporated.org) within 5 business days to schedule a scheduling meeting regarding my time off. 2. Once my time off is approved AND if I am required/doing a make-up day(s), I will update my Frequency List within 7 business days. CAPTCHA Δ
