Time Off Request Form

NOTE: You must submit this form at least five working days (Monday – Friday) in advance of the time you are requesting off.

First Name:

Last Name:


I would like to request these dates off:

During these dates, I’m scheduled to work at:

Will this request affect a scheduled classroom assignment?

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.”

Comments or questions about your request?

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