Request for Schedule time off
Request your leave details down below.
Name
*
First Name
Last Name
Employee ID
8 digit employee ID
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Position
*
Manager
*
Floor
*
MEDICAL
SURGICAL
ICU
NURSERY
OB
L&D
ER
Nursing Admin
Requested Dates
First Day requested off
-
Month
-
Day
Year
Date Picker Icon
Day you will return to work
-
Month
-
Day
Year
Date Picker Icon
Leave Type
Vacation
Personal
WOW
Other
Do you wish to use Plan 97 hours?
*
Yes
No
Comments
Request off with PRN Coverage
I am aware that the time is posted, I find it necessary to request off
Date
-
Month
-
Day
Year
Date
Schedule time
7-7 AP
7-7 PA
10-10
11-11
12-12
Other
I have arranged for (insert name) to work in my place
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
File Upload, please upload screen shot of conversation confirming coverage.
Browse Files
Cancel
of
Comments
Request off with Peer Exchange or Swap
I am aware that the time is posted, I find it necessary to request off
Date
-
Month
-
Day
Year
Date
Schedule time
7-7 AP
7-7 PA
10-10
11-11
12-12
Other
I have agreed to work their scheduled shift on
Date
-
Month
-
Day
Year
Date
Schedule time
7-7 AP
7-7 PA
10-10
11-11
12-12
Other
File Upload, please upload screen shot of conversation confirming coverage.
Browse Files
Cancel
of
Comments
Submit
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