This form must be completed and submitted to your Supervisor at least 2 weeks prior to your requested time-off start date. If submitted any later, it is not likely to be approved by CHH Management.
First Name:
Last Name:
Supervisor Name:
Your E-mail:
Client's Name:
Time Off Start Date:
Return to Work Date:
Total Time Off
Please check only 1 of the boxes and fill in the total shifts and/or hours that you will be taking off.
How much time do you need off?Hour(s)Full Day(s)
How many hours?
How many days?
Days and Hours Off
Please list the dates, days, and times that you would like to take off.
Date:
Day:
(example: Monday)
Time Off Start
(check AM or PM)
Time Off End
AMPM
Type of Leave
Please check leave type.
Personal LeaveSick LeaveVacation
Reason for Leave:
Supporting Documents: (i.e. doctor's note, obituary, jury duty, etc.)
Employee Signature:(Please type your name)
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