Employee Schedule Request Form

Use this form for all issues involving the current or future schedules. This form can be used for multiple purposes at the same time. When finished, click on "submit" and this form will be sent to both Nate and Ted. You will get a confirmation page which you should print or otherwise save for your records. Do not use this form for missed punches or for any requests less than 24 hours in advance. You can e-mail Ted or Nate for any issues not covered on this form.

Ambulance Schedule: October 21 to November 3, 2005

Ambulance Schedule: October 7 to October 20, 2005


INSTRUCTIONS:
Complete each section that applies to your request. You must have supervisor approval for all schedule changes. Dispatchers are not allowed to make schedule changes at any time.

I'm a part-time employee and available to work the following days on the next schedule:

Select schedule:

List only the dates you are AVAILABLE on the selected schedule: (Include any "issues" you may have.)


I am unable to work the following day(s) on the current schedule: (requires supervisor approval)
Shift Date Person covering your shift
on and has agreed to work for me.
on and has agreed to work for me.
on and has agreed to work for me.

I am unable to work the following days on the next schedule(s):
This box is only for employees who normally work a fixed schedule and need a specific day off or schedule change.
Vacation dates can be scheduled below.

Have you arranged for someone to cover your shift for you? (requires supervisor approval)

Yes
No

I   will be late
need to leave early		 on the current schedule. (requires supervisor approval)

Shift Date
I am scheduled for the on , and I would like to:

   Come in at what time:
   Leave by what time:

I am requesting the following period off for vacation:

My last day worked will be:
My first day back to work will be:

I am eligible for and am requesting to be paid the following: 

hours of vacation time.    hours of personal time.

Employee name:   Time clock badge number :   
Your e-mail address: