Child Development Center Request Time Off/Report an Absence

Requesting Time Off: Please submit your request at least one week prior. Reporting an Absence: This form should be used to report your absence in advance or on the day of your absence before the start of your shift.

Employee Name

Email Address

Phone

Work Location/Report To

Use the dropdown list to select the class you report to or your work location.

Use the dropdown list to select the person's name to whom you report to or check-in for work.

Start Date of Request/Report

Enter the start date you are requesting time off or the start date of your absence.

mm/dd/yyyy

End Date of Request/Report

Enter the end date of your requested time off or the end date of your absence.

mm/dd/yyyy

Return Date

Enter the date you will return/report back to work.

mm/dd/yyyy

Work Shift(Hours)

Enter your work shift hours (i.e. 11:30am - 2:00pm)

Total time Off Requested

Part Shift

Full Shift

Is this Time Off/Report an Absence request COVID related?

Yes

Did you complete an MSAC Employee Health Check Screening?

If you have any COVID-19 symptoms, fill out the Health Check Screening below. Employee Health Check| www.mtsac.edu/covid19/employee-health-check.html

Yes

Not Applicable(request is NOT COVID related)

Reason for Time Off or Absence

Comments

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