2021 Vacation/Time Off Request Form

Employee Name: Date of Request: / / 2021

# Unscheduled/Unused Hours Available to Employee: Vacatio _______________ Unpaid Sick: _______________

# of Hours Requested: _____ Vacation ______ Unpaid Time FMLA ____ Yes ____ No

First Day Off: / / 2021 Return to Work Date: / / 2021

If partial day, list the times you will work: Start: am/pm Stop: am/pm

If requesting unpaid days, please list the reason for the absence:

Please mark the days you will be off on the calendar below.
Company Holidays are highlighted in yellow.
Use "V" for vacation, "S" for Sick Time, "A" for unpaid absences, "F" for FMLA time.

2020

JANUARY FEBRUARY MARCH APRIL

S M T W T F S S M T W T F S S M T W T F S S M T W T F S
1 2 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3

3 4 5 6 7 8 9 7 8 9 10 11 12 13 7 8 9 10 11 12 13 4 5 6 7 8 9 10

10 11 12 13 14 15 16 14 15 16 17 18 19 20 14 15 16 17 18 19 20 11 12 13 14 15 16 17

17 18 19 20 21 22 23 21 22 23 24 25 26 27 21 22 23 24 25 26 27 18 19 20 21 22 23 24

24 25 26 27 28 29 30 28 28 29 30 31 25 26 27 28 29 30

31

MAY JUNE JULY AUGUST

S M T W T F S S M T W T F S S M T W T F S S M T W T F S
1 1 2 3 4 5 1 2 3 1 2 3 4 5 6 7

2 3 4 5 6 7 8 6 7 8 9 10 11 12 4 5 6 7 8 9 10 8 9 10 11 12 13 14

9 10 11 12 13 14 15 13 14 15 16 17 18 19 11 12 13 14 15 16 17 15 16 17 18 19 20 21

16 17 18 19 20 21 22 20 21 22 23 24 25 26 18 19 20 21 22 23 24 22 23 24 25 26 27 28

23 24 25 26 27 28 29 27 28 29 30 25 26 27 28 29 30 31 29 30 31

30 31

SEPTEMBER OCTOBER NOVEMBER DECEMBER

S M T W T F S S M T W T F S S M T W T F S S M T W T F S
1 2 3 4 1 2 1 2 3 4 5 6 1 2 3 4

5 6 7 8 9 10 11 3 4 5 6 7 8 9 7 8 9 10 11 12 13 5 6 7 8 9 10 11

12 13 14 15 16 17 18 10 11 12 13 14 15 16 14 15 16 17 18 19 20 12 13 14 15 16 17 18

19 20 21 22 23 24 25 17 18 19 20 21 22 23 21 22 23 24 25 26 27 19 20 21 22 23 24 25

26 27 28 29 30 24 25 26 27 28 29 30 28 29 30 26 27 28 29 30 31

31

Employee Signature:

* Employee must present documentation for unpaid absence to be excused (not count negatively toward attendance.)

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For supervisor to complete: Time off request is: Approved Pending - not yet approved

Denied - Reason:

Supervisor's Signature: Date / / 2021

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For HR to complete: Time off request is:

Excused: Yes No (Will count against employee for attendance and annual review.)

Original to HR Copy to Supervisor Copy to Employee Copy to Payroll