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Request for Time Off

Use this form to request any paid time off from your job.

1. The staff member: · completes the top section of this form · submits it to his/her supervisor at earliest possible date. 2. The supervisor: · verifies that the staff member is eligible for paid time off · completes the bottom section of this form

All paid time off should comply with University policy and further documentation may be requested. Policy questions may be directed to the Division of Human Resources, Office of Staff & Labor Relations (215-898-6093).

Name _______________________________________________________________________ Penn ID Number _________________ REASON DATE(S) ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ TOTAL TIME OFF: FURTHER EXPLANATION (when required)

__________________________________________________________________________________________________________ __________________________________________________________________________________________________________

Department _____________________________ # OF DAYS _________ _________ _________ _________ _________ _________ _________ _________ # OF HOURS __________ __________ __________ __________ __________ __________ __________ __________

s s s s s s s

Paid Time Off Sick Leave Comp Time Annual Military Duty Jury Duty Death in Family

(specify relationship below)

Other (explain below)

_____________________________________________________________ Employee signature

______________________________________ Date

SUPERVISOR'S RECOMMENDATION:

COMMENTS: ____________________________________ ____________________________________ ____________________________________

55000Pub/5.C/10.97/RC.MM

s s s

Approved Approved with following modification: Unapproved for following reason:

_____________________________________________________________ Supervisor's signature

______________________________________ Date

WHITE COPY: Supervisor

YELLOW COPY: Staff Member

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