CarePro Time Off Request Form

CAREGiver Time Off Request Form

Lancaster County
Time off requests are due at minimum 2 weeks in advance.

Call the office for any dates less than 2 weeks away.

(717) 207 - 0755

All time off requests are subject to approval.
Employee Name *
Email*
Phone Number
Request Off Date
Start Date*

MonthDayYear
Date
End Date *

MonthDayYear
Date
Purpose

PersonalVacationJury DutyPTOOther
Request Off Date
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Purpose

PersonalVacationJury DutyPTOOther
Request Off Date
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Purpose

PersonalVacationJury DutyPTOOther
Notes (comments, additional dates, etc.)
You will see a message on the screen after submitting your request confirming that we have received it. Your request is not official until the changes have been applied to your schedule. Please keeping an eye on your schedule, and if the changes have not been applied within 2 weeks of the requested time off, please call your schedulers.

Agree - I will check my schedule for requested changes and call after 3 business days if changes have not yet been applied.Disagree
Signature *
Typing your name here constitutes your electronic signature.
Office use only:

EnteredOpened shiftsUnavailable
Should be Empty:

CAREGiver Time Off Request Form