Time off Request
All sections must be filled out
Date of Request:
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Month
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Day
Year
Today's Date
Employee Name:
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First Name
Last Name
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R&P Time Off Policy
R&P policy states for every time off request you MUST give 30 days’ notice by filling out a time off request form. If you do not give 30 days’ your request will not be approved. Check WebPT 48 hours after submitting your time off request to see if that day was approved for you. You can use sick time for emergency’s/appointments/sick days. If you take a sick day, when you come back to work fill out a time off request for that sick day and hours you wish to use.*Vacation PTO bank rolls over up to 80 hours per year. Sick PTO bank rolls over40 hours per year. Time off will not always be approved…If you are a PROVIDER and you have patients scheduled for the day(s) you are requesting off, it will not be approved unless you have given 30 days’ notice. If you are office staff and you request a day off that cannot be filled by someone else, it will not be approved
I understand R&P's Time Off Policy:
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Please Select
YES
NO
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Request Information
Are you giving 30 or more days notice for this Time off Request?
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Yes
No
Please list the start and end dates for your time off request:
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Date you are returning to work:
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Month
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Day
Year
Date
Do you have patients scheduled during this request?
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No
I am not a provider
Yes; #
Are you taking a partial day off? Click to fill out section:
Are you planning to arrive to work late on your requested day? What time do you plan to be at work?
Are you planning to leave the clinic early on your requested day? What time do you plan leave the clinic for the day?
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PTO Request
Are you eligible to use PTO? Have you full-filled your 90-day probational period?
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Yes
No
This request is for:
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Vacation PTO
Sick PTO
I am in my 90-day probationary period
In total how many hours of PTO are you using?
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Do you have enough accrue PTO to take this time off?
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Yes
No
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Sign & Submit Request
I have filled out this request completely & understand I am using PTO for the days I have requested off:
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Clear
Comments regarding this request:
Submit
Should be Empty: