Axcelis PTO/Sick Time Off Request

The Axcelis employee MUST complete, sign and return this “PTO/Sick Time Off Request” form in order to be paid for sick leave or PTO.

Please Indicate: *

PTO

Sick Time

First Name: *

I attest that I used earned sick time for the authorized reason(s) checked below:

to care for my child, spouse, parent, or parent of my spouse, who is suffering from a physical or mental illness, injury, or medical condition that requires home care, professional medical diagnosis or care, or preventative medical care;

to care for my own physical or mental illness, injury or medical condition that requires home care, professional medical diagnosis or care, or preventative medical care;

to attend a routine medical appointment or a routine medical appointment for my child, spouse, parent or parent of my spouse;

to address the psychological, physical, or legal effect of domestic violence; or

to travel to and from an appointment, a pharmacy, or other location related to the purpose for which the time was taken.

For PTO please provide manager approval:

Direct Supervisor Signature:

Reset Signature

Direct Supervisor Name: *

Please provide the dates of your time off.

Date *

Number of Hours Taken

Date

Number of Hours Taken