Employee Time-Off Request
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
Must be @kvdentalarts.com email
Is the request for a full day off or a partial day off?
Full Day
Partial Day
Combination
Day/Time of Request
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of request start
Hour Minutes
AM
PM
AM/PM Option
Day/Time Returning to Work
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of request ending
Hour Minutes
AM
PM
AM/PM Option
Type of Leave
*
Please Select
Vacation
Family
Medical
Personal
Other
Please upload a doctors note outlining any restrictions and a timeframe for return.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Reason for Leave:
*
Does the office already have scheduled patients for the day(s)?
*
Yes
No
Can the schedule accommodate the request based on current staffing?
*
Yes
No
I will follow up with management to determine
Do you have PTO to cover your request?
*
Yes, please utilize PTO for the request
Yes, please do not utilize PTO for the request
No, I do not have the PTO to cover the request
I do not know if I have the PTO, and will look at my payroll portal
How much do you like Cliff?
*
1
2
3
4
5
Signature
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