Fillable Employee Paid and Unpaid Time Off Request Form

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Employee Paid and Unpaid Time Off Request Form

On average this form takes 8 minutes to complete

The Employee Paid and Unpaid Time Off Request Form form is 1 page long and contains:

  • 2 signatures
  • 2 check-boxes
  • 23 other fields

Country of origin: OTHERS
File type: PDF

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45 Knollwood Rd. • Elmsford NY • 10523
accounting@madisonapproach.com
914-428-4800
Employee Paid and Unpaid Time Off Request Form
Instructions: Fill out “Employee Section” in its entirety, sign and date, then print or save the form and
email to your Site Supervisor to complete the “Client Section”. When your Site Supervisor completes the
form, it then needs to be sent to our Payroll Administrator at accounting@madisonapproach.com
or
faxed to 914-428-5063.
Employee Section
First Name:
Last Name:
Email Address:
Phone Number:
Date(s) Requested Off:
Date to Return to Work:
Reason for Time Off: (select one)
PTO – Vacation (Must provide request 4 weeks in advance)
PTO – Planned Sick/Personal (Must provide request 4 weeks in advance, or as soon as practicable)
FMLA Qualified Event
Documentation attached
Will be sent separately
PFL Qualified Event
Documentation attached
Will be sent separately
Employee Signature ____________________________ Date ___________
Client Section
Company Name:
Supervisor Name:
Email:
Phone:
Are the above dates approved? Yes No
Do you require us to find you coverage for the absence? Yes No
Are you otherwise satisfied with the work performance of this employee? Yes No
Comments:
Supervisor Signature ________________ Date_____________
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Employee Paid and Unpaid Time Off Request Form

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Completed 17 February 2022

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