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Time Off Request

Full Name

Date(s) Requested

Include exact dates and times of requested absence.

Next Scheduled Shift After Absence

Example: “Friday, November 15, 9:00 AM – 2:00 PM”

Type Of Time Off Request

Paid Sick Time (California Labor Code §246)

Bereavement (Immediate Family Only)

Jury Duty / Legal Obligation

Professional Licensing Exam / Education

Other (requires management approval)

Acknowledgement

I understand that time off is not guaranteed and is subject to management approval based on scheduling needs and documentation requirements under California labor law.

I confirm that the information provided is true and accurate. Falsifying a reason or failure to follow the proper request procedure may result in disciplinary action, up to and including termination.

Signature