Time Off Request Form

Time Off Request

Please note that all Time Off Requests must be made 2 weeks in advance of the date(s) requested.
Name*

First NameLast Name
Date*

MonthDayYear
Date
E-mail*
Contact Number*

Area CodePhone Number
Primary Department:*

Community LivingCommunity Integration- East/ ADSCommunity Integration- TibbsCommunity Integration- Campus (Mary Rigg/ Noblesville)DHI/PAC/RSPOProgram Manager/DirectorOther
Supervisors Email Address:
example@example.com
What Site(s) do you work at:*

Site 1Site 2Site 3Site 4Site 5Site 6Site 7Site 8Site 9Site 10Site 11Site 12Site 13Site 14Site 15Site 16Site 17Site 18Site 19Site 20Admin StaffOther
Start date of time off:*

MonthDayYear
First day of your time off
Last date of time off: *

MonthDayYear
Last day of your time off
Total hours requesting off? *
Reason*
Do you have PTO available to cover this request?*

YesNoOther
Is the length of time off being requested greater than 1 week? *
Use of PTO or Sick Time in excess of one week which would meet the requirements for a Leave of Absence will be treated as a leave, regardless of the available benefit time, and may be subject to the guidelines established under the Family and Medical Leave Act. A Military Leave will be treated as any other leave of absence for the purpose of benefit time calculation.

Please reach out to the Human Resource Director as soon as possible. 317-375-2701 or HR@mynoblelife.org or complete the Noble Leave Request form at: https://form.jotform.com/eh3/RequestForLeave
Is this request being made 2 weeks in advance? *
Due to the request not being made in advance as stated in HR Policy #1.7, you acknowledge that your time off will count as an attendance occurrence and may be subject to corrective action.*
Additional Comments
Please note that by submitting this form it does not guarantee approval of your request.

Once your request is submitted you will recieve written approval from your Supervisor.

Once you receive approval you will be responsible for entering your PTO into AccelTrax prior to your time off.
PP #5.3 Paid Time Off/ Sick Benefit Time
Human Resources Procedure #5.6
Employee Signature: *

Clear
Should be Empty: