Time Off Request Form

First Name:

Last Name:

Email:

I would like to request these dates off: From: To: All day These times:

During these dates, I’m scheduled to work at:OceansideSan ElijoCommunity Learning Center

Will this request affect a scheduled classroom assignment? Yes If yes, provide Instructor(s): Class(es): No

Will you be using your personal business (PB) hours for this time off?**According to the Healthy Workplaces, Healthy Families Act of 2014 (AB 1522), PB time can be used for the following purposes: “diagnosis, care, or treatment of an existing health condition of, or preventative care for, yourself or a family member (parent, child, spouse, domestic partner, parent-in-law, sibling, grandchild or grandparent) or for specified purposes if an employee is a victim of domestic violence, sexual assault or stalking.” Yes No

Comments or questions about your request?