DITP Need Request Form

Todays Date

Managers Name

Email Address

Phone Number

Phone

Unit/Dept

Entity

Proposed Start Date

mm/dd/yyyy

Number of Individuals requesting

Shift Requesting Coverage for

If selected other please provide details below

Is this request for a new start?

YES

If requesting an Extension Provide RN's Name

*Please Note: RN's can only have one extension on Unit.

The answers to the following questions related to the list below; are needed to assist with allocating our resources of ITP RN's:

Budgeted FTE

Functional Vacancy rate?

What is your functional Vacancy rate for period requesting coverage?

FTE's

What is your current number of filled fte's?

Number of employees presently in Orientation

Number of employees on Continuous FMLA

Additional Comments

Send me a copy of my responses

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