APPLIED HOME CARE, INC.EMPLOYEE SCHEDULE CHANGE REQUEST
Complete one form for each client requiring coverage.
EMPLOYEE INFORMATION
Employee Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
CLIENT & SHIFT INFORMATION
Client Name
*
First Name
Last Name
Client Address
*
Street Address, City, State, Zip Code
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Telephone Number
*
Format: (000) 000-0000.
Date(s) of Shifts Needing Coverage
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date Available to Return to Work
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
REASON FOR ABSENCE
Reason for Absence
Family
Emergency
Medical
Personal
Vacation
Other
COVERAGE ARRANGEMENT
Coverage Arrangement
Replacement caregiver needed
Swapping shifts with another caregiver
Replacement / Swap Caregiver Name (if known)
First Name
Last Name
IMPORTANT SCHEDULING NOTICE
To ensure our patients receive quality care without any lapse in service, notify the office of a schedule change as soon as you become aware of an event that will prevent you from working a scheduled shift. Schedule changes reported less than 24 hours before the affected shift may result in the absence being classified as a no-call/no-show.
Please allow 1-2 weeks for approval. Contact the office upon submission.
All schedule changes and coverage arrangements require management approval.
EMPLOYEE ACKNOWLEDGMENT
Employee Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
OFFICE USE ONLY
Status
Approved
Denied
Management Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submitting this form does not constitute approval of the requested schedule change.
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