Time Clock Correction and Leave Request Form Advanced Pediatrics Once signed please make 3 copies, original to Lisa, copy to Lori, place copy in & keep Aprill’s box one Time clock correction or Leave request (Circle One) Employee Name: _________________________ ID #___________Date____________ Date Day Correct Correct Correct Correct Normally Total hours IN OUT IN OUT Scheduled Hours PTO or LWOP to Mon Tues to Wed to Thurs to Friday to Sat to Sun to Mon to to Tues Wed to Thurs to to Friday to Sat to Sun PTO must be used prior to requesting leave without pay. Do you have accrued leave? ___Yes ___No TOTAL HOURS OF LEAVE ON YOUR LAST PAYSTUB: __________ Dates requested off Date ___________ to ____________ or partial days off Coming in late on __________ at __________am/pm Leaving early on ___________at _________am/pm Total Number of Hours you are Total Hours PTO____________ Total Hours LWOP___________ requesting off PTO_______ Holiday ______ Other________ Type of Leave LWOP________(only to be used when PTO is exhausted) Overstaffing LWOP_______ __________________________________ __________________ Signature Date Employee’s ________________________________ __________________ Signature Date Supervisor’s
Time Clock Correction and Leave Request Form Advanced Pediatrics Once signed please make 3 copies, original to Lisa, copy to Lori, place copy in Aprill’s box & keep one Time clock correction or Leave request (Circle One) Employee Name: _________________________ ID #___________Date____________ Date Day Correct IN Correct OUT Correct IN Correct OUT Normally Scheduled Hours Total hours PTO or LWOP Mon to Tues to Wed to Thurs to Friday to Sat to Sun to Mon to Tues to Wed to Thurs to Friday to Sat to Sun to PTO must be used prior to requesting leave without pay. Do you have accrued leave? ___Yes ___No TOTAL HOURS OF LEAVE ON YOUR LAST PAYSTUB: __________ Dates requested off or partial days off Date ___________ to ____________ Coming in late on __________ at __________am/pm Leaving early on ___________at _________am/pm Total Number of Hours you are requesting off Total Hours PTO____________ Total Hours LWOP___________ Type of Leave PTO_______ Holiday ______ Other________ LWOP________(only to be used when PTO is exhausted) Overstaffing LWOP_______ __________________________________ __________________ Employee’s Signature Date ________________________________ __________________ Supervisor’s Signature Date
advanced-pediatrics-employee-handbook-final-may-4-2016.docx