Time Off Request Form printable pdf download

Time Off Request Form

TIME OFF REQUEST FORM

Household Employee:____________________________________

PERSONAL TIME OFF REQUESTS

Paid Time Off: Begins to accrue after 90 days of employment. Requests for PTO of two or more

days must be submitted at least two weeks in advance.

Bereavement Leave: Up to three days of paid leave is available for a death in the immediate

family.

Start date

End date

Hours

Personal time off

Bereavement

Jury duty/witness

Military service

Total paid time off

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VACATION REQUESTS

Vacation Instructions: Please submit your vacation request at least four weeks in advance of

START DATE.

Start date

End date

Hours

Employer

approval

choice

Total paid time off

Household Employee Name:________________Date:____________

Employer Name:__________________________Date:___________

Time Off Request Form