Time-Off Request Form

Please review the most current Employee Handbook for full details on all policies related to time-off.

Do not complete this form for an FMLA request. If you would like to request a FMLA leave, it must be emailed to the Human Resources Department (HR@qtctherapy.com) via the procedure in the Employee Handbook.

Form submissions missing information will not be accepted and may cause a delay in processing. If you have any questions regarding your time-off request, please email the PTO Department (PTO@qtctherapy.com).

Special Considerations: Time off includes the end of the month treatment log collection. Time off is during peak holidays / summer months.

Time-Off Request Form

Fields marked with a * are required.

As of last pay period (the number of available of hours).

Must be within the same pay period.

If applicable, enter the date(s) and hour(s) you will be making up in the fields below. If you need additional space, please use the Additional Comments section below.

Please prove you are human.

REQUIRED: After submitting your request, check your email and print out your filled out Time-off Request form, then place a printed copy of your submitted request in your facility’s Time-Off Request Binder.