Sick and Safe Time Request Form

Thank you for using the online Sick and Safe Time Request Form. The purpose of this form is to request use of your accrued sick/safe time. Please allow up to 7-10 business days for processing of your accrued sick time.

Integra Health Care will pay out up to the amount of your actual accrued balance at the time this form is submitted. You will not be paid for future or assumed hours. Your accrued balance, if applicable, is available to you on your most recent paycheck.

Slick and Safe Time Request Form

Your Name (First and Last Name)

First

Last

Your Email Address

Your Phone Number

Request start date of sick time

Request end date of sick time

Total # of sick time hours requested

Integra will pay out up to the amount of your accrued balance

Are/were you scheduled to work this day(s)

Yes

No

Acknowledgement

I acknowledge that I have accrued the hours that I am requesting

I acknowledge that it will take 7-10 business days for processing before payout of my accrued sick time