Request for TIME OFF (RTO) — Meaningful Outcomes

Behavioral Health Services

Todays Date

MM

DD

YYYY

Name

First Name

Last Name

Email

Supervisor

Number of Days Requesting

Total Number of Hours Requested

Dates Requested & Times (please place client initials next to each shift to be covered)

Type Requested (select one)

PTO

Unpaid

Bereavement

Jury Duty

Leave of Absence