Time Off Request Form


The purpose of this document is to inform A Homemade Plan in writing that you, permanently or temporarily, wish to be taken off an assignment. Below, please find questions regarding further details to the reason(s) why you are making this request. You must fill out ALL of the following questions. Any incomplete form will be interpreted as you quitting employment with A Homemade Plan.  A Homemade Plan would like to reiterate our call out policy which is as followed:

If for any reason you need to call out of work, you must give A Homemade Plan at least 24 hour notice. It is understandable that this may not be possible in all cases so please do your best to meet this requirement. A no-call no-show will result in loss of work opportunities and will be reported to the Maryland Board of Nursing and the Office of Health Care Quality as neglect. You must call the local A Homemade Plan Office and speak directly to a member of the office staff when requesting time off. If you are requesting time off on short notice and are unable to inform a member of the A Homemade Plan office staff during office hours (which are Monday – Friday from 8AM-5PM) then you must call the after-hour cell phone at 410-972-7183 and speak with an office staff member. ***Furthermore, you may not request off by leaving a voice message, text message, email or by solely filling out this form, you must speak to a member of the office staff. Please understand that these processes are in place to keep our patients safe in their homes.

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