↑↓ Time Off Request Form (TOR)

Important Notice!

Access the NEW TOR FORM here.

Click the link above ↑

Submit time-off requests for review: 1–2 days off (2 days notice); 3–4 days (1 week); up to 5 days (1 month). ⚠️ Sick leave of 3+ consecutive days or frequent absences may require a doctor’s note. See the Time Off Policy & Procedures for full details.

Employee Name

Select Date TODAY

Department

Supervisor

📌 Time-Off Request / Absence from Work

To ensure staffing and operational needs are met, the Company reserves the right to approve or decline requests at its discretion. Requests must be coordinated and approved by the supervisor/COO, subject to operational requirements.

Is this request a revision or reclassification of a previously requested leave?

Yes No

Reason of request

⚠️ Late requests may be treated as unscheduled.

Start Date of Absence

START Date

Last Day of Absence

END Date

# of Days Off Work

# work days only

Apply all time off days as

Whole Day/s

full hours of the shift

Partial

Early Off, Late Arrival, Away in between shifts

Scheduled Partial Time Off:

Late Arrival Early Off Away in between shifts

" Whole + Partial Days

Identify the dates for full days and partial days, and time, for proper computation.

Partial Day's Time of Arrival (ETA), Departure (ETD)

write the date/s and time for arrival | departure | duration if away

Select * CFRA (CA Family Rights Act) for approved statutory leaves such as: Bonding Leave, Family Care Leave, Personal Medical Leave . More info HERE.

Select * CFSPA (School-Related Activities) for childcare or school-related reasons, check eligibility and more information about this leave HERE. Absences may be reclassified if submitted under a different category, as long as hours have not been maximized.

* VACATION or PERSONAL may be selected for leisure, appointments, family or personal matters, etc.

Please make sure you still have available CA paid sick leave hours, otherwise, select a different reason code from above.

Apply PSL for

Self

Own personal illness or wellness

Family Member (Kin Care)

Care for a qualified family member

Name of family member and relationship to you

Brief explanation (add dates if necessary):

This information is not intended to provide or know a medical diagnosis; if you have serious concerns, please consult your healthcare provider.

USE OF VACATION HOURS MAY BE REQUIRED.

Up to 8 hours per month, 40 hours of leave per calendar year for full time employees, proportionate number for part time employees (for school-related leave).

Brief explanation:

Information about your absence. Please make sure you select the appropriate reason code (example: school activities should be CFSPA).

Personal or Vacation Reasons

Vacation

relaxation, break, leisure activities

Personal Matters

appointments, family, other personal matters

Religious Observance

religious practices, ceremonies, or holidays

Upload Jury Duty Summon

Add file

Please upload a file

Bereavement Leave - Death of qualifying family member: You may be asked to provide acceptable documentation within 30 days of the first day of leave.

Spouse

Child

Parent

Sibling

Grandparent

Grandchild

Domestic Partner

Parent-in-Law

Type of school related leave:

School Involvement Leave

general school matters

School Disciplinary Leave

meetings on disciplinary measures

Select reason for general school matters (non-disciplinary) *limited hours:

School or Daycare Activities/Functions Enrollment-Related Appointments School or Child Care Provider Emergency Field Trips, Facility Visits Parent-Teacher, IEP Meetings Behavioral Meetings

Select reason for disciplinary matters:

Initial, Disciplinary Meetings Follow-up, Disciplinary Hearings

Details of your need to take this leave:

example: school program, awards ceremony, back-to-school night, open house, etc.

IMPORTANT! Employees are required to provide reasonable notice of absence. You may be asked to provide PROOF OF PARTICIPATION from the school. Use of accrued paid time off can be generally required under this section of the state labor code. CFSPA Link.

Reasons for leave under CFRA and/or FMLA

Bonding Leave Family Care Leave

Care for covered family member with med certification

Placement of a Child

Adoption or foster care

Personal Medical

Employee's own serious health condition

Qualifying Military Exigency

Reasons for Military Leave

Active Duty Training Deployment Emergency Deployment Family Military Obligations

deployment ceremonies, support during military service, handle legal/admin matters

Bereavement Leave during 3 months after the death of qualified family member For eligible employees

Paid Leave - Day # 1

Paid Leave - Day # 2

Use of VL for the remaining Bereavement days (2 days paid already)

How leave is taken

Continuous Leave

single, uninterrupted period of absence

Intermittent Leave - small increments

taken in separate blocks of time

2-week increments for Bonding Leave

of birth, adoption, foster care

< 2wks duration for Bonding Leave

of birth, adoption, foster care

Take note for Bonding Leave:

Child Bonding Leave does not have to be taken all at once, but must be completed within one year of the child's birth, adoption, or start of foster care.
You can take CBL in separate "blocks" of at least two weeks at a time. On two occasions, you can take CBL of less than two-week increments. After that, the company can require your CBL to be taken in a minimum of two-week increments.

Name of Qualified Family Member (not yourself)

Relationship to you

Date of Death of Qualified Family Member

Bereavement Leave Paid Hours:

Check your accrued Vacation Hours or Sick Leave balances on your ADP app.

Review the CA Paid Sick Leave Law. If you want to use SL for laboratory, doctor's appointments, etc., please change your selected reason to "CA Paid Sick Leave" above, if you have available SL balance.

I will use CA Paid Sick Leave for reasons related to health

and for purposes stated in the CA Paid Sick Leave Law.

I will use *paid VL for my CFRA or other statutory-related absence.

*available accrued vacation hours

I will use my VL for my Pregnancy-related absence.

*available accrued vacation hours

⏰ TIME OFF POLICY REMINDER

Vacation Leave (VL) must be used for certain leaves before unpaid time off will be considered.
Unpaid time off may only be granted once all VL is used and remains subject to approval.
Time off taken will be deducted from your VL or Sick Leave (SL) balance.
Employees are responsible for tracking their own balances before submitting requests.
👉 Review the Time Off Policy in the ADP Portal for full details.

Action:

COVID-19 Leave

For absence related to COVID-19

By completing this form, I attest that I am unable to work or telework for the following reason: complete all form fields as possible

(1) I am subject to a Federal, State, or local quarantine or isolation order related to COVID-19.

(2) I have been advised by a health care provider to self-quarantine due to concerns related to COVID-19.

(3) I am experiencing COVID-19 symptoms and seeking a medical diagnosis.

(4) I am caring for an individual subject to an order prescribed in (1) or self-quarantine as described in (2).

(5) I am caring for a son or daughter whose school or place of care is closed (or child care provider is unavailable) for reasons related to COVID-19.

(6) I am experiencing a substantially-similar condition specified by the Secretary of Health and Human Services, in consultation with the Secretaries of Labor and Treasury.

(7) COVID-19 vaccination for my self

NAME and CONTACT details of (a) the government entity, (b) health care provider that issued the quarantine or isolation/self-isolation order, OR (c) vaccination location.

Start Date of Isolation:

Exposure:

I am infected with coronavirus I am recorded as a close contact

Name of Person in Need of Care

Relation to Employee:

Details of your appointment (Name of Facility, Contact Person, Contact Info, Purpose, Others)

Name(s) of son(s) and/or daughter(s) being cared for:

Age:

Name(s) of son(s) and/or daughter(s) being cared for:

Age:

Name(s) of son(s) and/or daughter(s) being cared for:

Age:

Name & address of school, place of care, or child care provider that has closed or become unavailable:

By completing this reason section above (#5), I also affirm that no other person will be caring for the above-named son(s) or daughter(s) during the period for which I am requesting paid sick leave. I further affirm that if the above-named son(s) and/or daughter(s) are over the age of 14 and care is needed during the daylight hours that special circumstances exist requiring me to provide care.

IMPORTANT!!! For COVID-19 related absence, please click this link to access additional forms.

📑 Request Guidelines

Submit requests before scheduling appointments or travel plans; all requests are subject to approval.
Submitting a TOR after the fact does not excuse tardiness or attendance infractions.
Planned absences → submit in advance; Unplanned absences → file the Unscheduled Time Off Form within the same pay period and notify HR.
👉 Review the Time Off Procedures for complete details.

📧 Automated Form Notice

A confirmation will be emailed to the address you enter—please ensure it is correct.
Requests are recorded based on company business hours; those sent after hours will be considered received the next business day.
For questions, contact HR at neb-hr-compliance@nebgrp.com

⚠️ Absences over 5 consecutive days require a written explanation sent to HR (neb-hr-compliance@nebgrp.com) and will be reviewed to determine if they qualify as extraordinary cases.
⚠️ Doctor’s note may be needed for 3+ sick days or multiple absences.

☑️ ATTESTATION
I certify that the information provided above is true and correct. I understand it is my responsibility to comply with company rules and policies. For certain leaves, proof or certification may be required. This request is submitted pending manager or management approval.

☑️ ACKNOWLEDGEMENT AND COMPLIANCE
By submitting a vacation request, I acknowledge that I have read and understood this policy. I agree to follow the procedures outlined to help ensure smooth operations during my absence. I understand that non-compliance may result in denial of vacation requests or disciplinary action.

e-Signature

Email address

Your information will be encrypted.

↑↓ Time Off Request Form (TOR)

Access the NEW TOR FORM here.

📌 Time-Off Request / Absence from Work

Please make sure you still have available CA paid sick leave hours, otherwise, select a different reason code from above.

Check your accrued Vacation Hours or Sick Leave balances on your ADP app.

For absence related to COVID-19

IMPORTANT!!! For COVID-19 related absence, please click this link to access additional forms.

Northeast Billing Group | NE Billing