Employee Time Off Request Form - DOC - DOC

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					                                              IRCO EMPLOYEE TIME OFF REQUEST FORM

Employee Name:                                                                    Program(s):

Pay Period: ________________________________________


 Dates Requested             Number of Hours                             Reason                                 Compensation Request

                                                                                                         *PTO Hours:
                                                                                                         *No Pay Hours:
                                                                                                         Bereavement Pay Hours:
                                                                                                         Court Pay Hours:
                                                                                                         □ Check Box if FMLA/OFLA Time
Comments:

                                                                   _____________________________________________________
                                                                   Employee Signature                               Date


                                                                   _____________________________________________________
                                                                   Supervisor(s) Signature                          Date

Complete this form for all needed time off and submit form to your supervisor(s) for signature and approval. Approval is contingent upon it being allowable
by IRCO policy and PTO approval is contingent upon employee having PTO available at the time it is taken. *PTO requests of more than two continuous
weeks or unpaid time off in excess of 3 days must have the Executive Director’s approval and notify human resources.

             White Copy: Fiscal        Yellow Copy: Employee          Pink Copy: Supervisor          Fiscal Form #101          Rev 10/01/09



                                              IRCO EMPLOYEE TIME OFF REQUEST FORM

Employee Name:                                                                    Program(s):

Pay Period: ________________________________________


 Dates Requested             Number of Hours                             Reason                                 Compensation Request

                                                                                                         *PTO Hours:
                                                                                                         *No Pay Hours:
                                                                                                         Bereavement Pay Hours:
                                                                                                         Court Pay Hours:
                                                                                                         □ Check Box if FMLA/OFLA Time
Comments:

                                                                   _____________________________________________________
                                                                   Employee Signature                               Date


                                                                   _____________________________________________________
                                                                   Supervisor(s) Signature                          Date

Complete this form for all needed time off and submit form to your supervisor(s) for signature and approval. Approval is contingent upon it being allowable
by IRCO policy and PTO approval is contingent upon employee having PTO available at the time it is taken. *PTO requests of more than two continuous
weeks or unpaid time off in excess of 3 days must have the Executive Director’s approval and notify human resources.

             White Copy: Fiscal        Yellow Copy: Employee          Pink Copy: Supervisor          Fiscal Form #101          Rev 10/01/09

				
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