Confidential — For Internal Use Only
Submit This Form At Least 7 Days In Advance. Emergency Requests Should Be Submitted As Soon As Possible.
Section 1: Employee Information
Field | Details |
Full Name | |
Employee Id | |
Position | ☐ Server ☐ Cook ☐ Bartender ☐ Host ☐ Dishwasher ☐ Manager ☐ Supervisor ☐ Runner ☐ Barista ☐ Other: _______ |
Department | ☐ Front Of House ☐ Back Of House ☐ Bar ☐ Management |
Direct Supervisor | |
Contact Number | |
Date Submitted (Dd/Mm/Yyyy) |
Section 2: Request Details
Field | Details |
Type Of Time Off | ☐ Paid Time Off (Pto) ☐ Unpaid Leave ☐ Sick Leave ☐ Emergency Leave ☐ Parental Leave ☐ Study / Exam Leave ☐ Other: _______ |
Start Date (Dd/Mm/Yyyy) | |
End Date (Dd/Mm/Yyyy) | |
Total Shifts Requested Off | |
Total Days Requested Off |
Specific Dates & Shifts Required
# | Date (Dd/Mm/Yyyy) | Day | Shift |
1 | ☐ Opening ☐ Mid ☐ Closing ☐ Full Day | ||
2 | ☐ Opening ☐ Mid ☐ Closing ☐ Full Day | ||
3 | ☐ Opening ☐ Mid ☐ Closing ☐ Full Day | ||
4 | ☐ Opening ☐ Mid ☐ Closing ☐ Full Day | ||
5 | ☐ Opening ☐ Mid ☐ Closing ☐ Full Day | ||
6 | ☐ Opening ☐ Mid ☐ Closing ☐ Full Day | ||
7 | ☐ Opening ☐ Mid ☐ Closing ☐ Full Day |
Need More Rows? Attach A Separate Sheet.
Section 3: Reason For Request
Reason | Details |
Primary Reason | ☐ Vacation / Holiday ☐ Medical / Health ☐ Family Responsibility ☐ Bereavement ☐ Study / Examination ☐ Religious Observance ☐ Mental Health Day ☐ Personal Matter ☐ Other: _______ |
Is A Medical Certificate Required? | ☐ Yes — To Be Submitted By: ___________ ☐ No ☐ N/A |
Have You Arranged Shift Cover? | ☐ Yes — Covered By: ___________ ☐ No ☐ Working On It |
Additional Notes:
Section 4: Employee Declaration
I Confirm That The Information Provided Is Accurate. I Understand That This Request Is Subject To Operational Requirements And Management Approval, And That Approval Is Not Guaranteed.
Employee Signature | Date (Dd/Mm/Yyyy) |
Section 5: Management Review
Field | Details |
Pto / Leave Balance (If Applicable) | Available: _______ Days Used: _______ Days Remaining: _______ Days |
Conflicts With Other Requests? | ☐ Yes ☐ No |
Conflicts With Peak / Busy Period? | ☐ Yes ☐ No |
Shift Cover Confirmed? | ☐ Yes ☐ No ☐ N/A |
Decision
Status | Reason (If Denied) | |
☐ Approved ☐ Denied ☐ Partially Approved |
Partially Approved — Approved Dates Only:
Manager Notes:
Field | Details |
Manager Name | |
Manager Signature | |
Date Of Decision (Dd/Mm/Yyyy) | |
Entered into the Scheduling System? | ☐ Yes ☐ No |
Employee Notified? | ☐ Yes — Date: ___________ ☐ No |
Form Version: 2.0 | Date Format: Dd/Mm/Yyyy Throughout For Questions, Contact Your Direct Supervisor Or The Hr / Scheduling Manager.