Name *

First

Last

Email *

Start Date *

End Date *

Total Days *

Paid or unpaid? *

Paid
Unpaid

Is this an amended request? *

Yes
No

Do you have another submission? *

Yes
No

Start Date *

End Date *

Total Days *

Paid or unpaid? *

Paid
Unpaid

Is this an amended request? *

Yes
No

Do you have another submission? *

Yes
No

Start Date *

End Date *

Total Days *

Paid or unpaid? *

Paid
Unpaid

Is this an amended request? *

Yes
No

Your submission is not finalized and will not be sent until you’ve completed each field and have signed & dated this form. Please digitally initial the following policies to indicate you’ve read and agree to them.

Employee understands that if they have no additional paid absence days remaining, and request paid time anyway, they may be given the time off but may not be notified that the day will be unpaid instead. Therefore, it is highly recommended that employees keep track of their own absences for their own budgeting purposes. *

I have read and understand

Employees will find their APPROVED planned absence days listed on the Employee Schedule, color coded in GREEN. Denials will be communicated via DM (direct message) on CVH’s Communication App (such as Slack). It will remain the EMPLOYEE’S RESPONSIBILITY to check the Employee Schedule to ensure that the correct days were awarded off. *

I have read and understand

Employees understand that in order to pay our team and serve our patients, the hospital has to remain open. This could mean that requests for time off are denied. *

I have read and understand

In the event that multiple employees have requested the same time off, management will award the time off to the employees with the highest performance in development meetings and highest work performance. *

I have read and understand

Dependent upon many circumstances, management may require you find a current employee with a comparable skill set to cover for you. If this is the case, they will notify you and communicate with you via CVH’s Communication App. *

I have read and understand

Signature *

Clear Signature

Date *

Employee Forms

Planned Absence Request

Planned Absence Request

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