Time Off Request Form Date Request Submitted(Required) Name(Required) First Last Email(Required) Employee Role/Department(Required) Front Desk Technician Instrument Tech Surgery Scribe Provider TIME REQUESTED OFF IN ADVANCE:Please add the date(s) below and select if you are requesting a Full Day OFF, to come late to work, or to leave early.Requested Date Number of Hours Requested OffRequest TypeSelect TypeFull DayCome LateLeave EarlyReasonRequested Date Number of Hours Requested OffRequest TypeSelect TypeFull DayCome LateLeave EarlyReasonRequested Date Number of Hours Requested OffRequest TypeSelect TypeFull DayCome LateLeave EarlyReasonRequested Date Number of Hours Requested OffRequest TypeSelect TypeFull DayCome LateLeave EarlyReasonRequested Date Number of Hours Requested OffRequest TypeSelect TypeFull DayCome LateLeave EarlyReasonTotal Hours Requested OffPast Tense - PTO RequestsUse this section only for Days/Times you have already missed. This is for past dates only - IE: call outs or had to leave unexpectedly. Do not use this section to request time off in the future. Please Add PTO to these Dates(s):Total Unexpected PTO Hours:Time off requests must be submitted via this form which will be emailed to Kim & April. Requests that do not use this form will be denied and must be resubmitted to be considered. Please check the PTO Calendar before submitting a request. All Staff have access to view the PTO Calendar. Only ONE Staff member per department/role will be approved on days with a provider scheduled. Please submit requests 2 weeks in advance for staff and 6 weeks in advance for providers. Thank you.