TIME OFF WORK REQUEST Survey

Please use this form to submit requests for time-off, including Paid Time Off (PTO), Personal Day(s) planned in advance, and other leave. Upon submission, your request will be received by Roncelli's HR Manager.

Personal Day(s) requested the same day (e.g. emergency or sick day) require an email to your Supervisor and the HR Manager; they will record your same day Personal Day on your behalf.

Please note that submitting a request does not guarantee approval of time off. Approval is subject to the approval of your direct supervisor, and subject to all terms and conditions of the most recently published version of Roncelli's Employee Handbook.

Roncelli's HR Manager will contact you via email within (3) business days of your Request for Time Off to notify you of the status of your request, and remaining balance of PTO and Personal Days available.

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* 1. General Information

What is your name?

What is your Roncelli email address?

What is your supervisor's name?

What is your supervisor's email address?

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* 2. What type of time off are you requesting?

Paid Time Off (e.g. vacation)

Personal Day(s) Planned in Advance (NOT FOR VACATION, e.g. for planned medical, family matters, personal matters)

Bereavement Leave

Jury Duty or Court Appearance Leave

Military Leave (HR will follow-up for further processing)

FMLA Leave (e.g. childbirth/care, adoption, serious health) (HR will follow-up for further processing)

Leave Without Pay

Other (please specify)

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* 3. When is the first day of your requested time off?

Date

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* 4. When is the last day of your requested time off?

Date

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* 5. How many total days off work are you requesting? (Don't count holidays, and don't count weekends unless your job requirements include weekends)

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* 6. To the degree that you feel comfortable, can you please describe the reason for your requested time off?

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* 7. Coverage of my responsibilities:

I have reviewed the Company Wide PTO calendar, assert that my responsibilities are adequately covered during my absence, and have cleared my absence with the person who will be covering my responsibilities.

I have coordinated by absence with my department, and with the person covering my responsibilities.

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* 1. General Information

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* 2. What type of time off are you requesting?

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* 3. When is the first day of your requested time off?

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* 4. When is the last day of your requested time off?

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* 5. How many total days off work are you requesting? (Don't count holidays, and don't count weekends unless your job requirements include weekends)

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* 6. To the degree that you feel comfortable, can you please describe the reason for your requested time off?

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* 7. Coverage of my responsibilities:

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* 8. Who has agreed to cover your responsibilities in your absence?