Time Off Request

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SOMERSET-PULASKI COUNTY EMS

TIME OFF REQUEST

(Vacation or Holiday)

USE ONLY ONE (1) FORM PER DAY OFF

Date

Time

Employee

Date Requested Off:

Time Period:

Time

to

Time

Total Hours:

Type Of Time Used:

VACATION

HOLIDAY TYPE

PERSONAL DAY

BEREAVEMENT

SCHOOL

JURY DUTY

ADVANCED SICK TIME

WEATHER TIME

THIS FORM MUST BE SUBMITTED 14 DAYS BEFORE REQUESTED TIME OFF TO EITHER THE PLANNING MAJOR OR OIC. IF SUBMITTED AFTER THAT DAY, IT IS AT YOUR RESPONSIBILITY TO FILL YOUR SHIFT IN REGARDS TO THE DEPARTMENT STAFFING AND TIME OFF GUIDELINE. IF MORE THEN FOUR (4) PERSONNEL ARE OFF ON HOLIDAY OR VACATION, TIME OFF WILL NOT BE AWARDED.

Employee Signature

Office Use Only

Date

Time

OIC / MAJOR

Admin Use Only

Approved:

Yes

No

If Denied, Reason:

Major

Chief

*COPY TO OFFICE MANAGER AND HUMAN RESOURCES

ORDER OF REQUEST FOR DATE:

NUM

OF

NUM

Person(s) To Be Notified (use A Comma To Separate Email Addresses; Do Not Add a Space After the Comma)