Policy Manual sample

MDT Home Health Care Agency, Inc. TIME OFF REQUEST FORM I WOULD LIKE TO REQUEST THE FOLLOWING TIME OFF: (Complete appropriate section) REASON NO. OF HOURS/DAYS DATE(S) REQUESTED UNPAID TIME OFF ____________________ _________________________ PAID TIME OFF ____________________ __________________________ ____________________ __________________________ I UNDERSTAND THIS REQUEST MUST BE APPROVED IN ADVANCE BY MY DIRECTOR. ______________________________________ ______________________________________ EMPLOYEE SIGNATURE SUPERVISOR APPROVAL ______________________________________ ______________________________________ DATE DATE Home Health Agency. - - Personnel/Operations Policies B-133