Self-Care Pause Request Form
Use this form to formally request a self-care break. Please provide accurate details to ensure your request is processed smoothly.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Department/Team
*
Please Select
Human Resources
Finance
Operations
Marketing
IT
Other
Role/Position
Reason for Self-Care Pause
*
Mental health
Physical health
Personal matters
Family emergency
Other
Please provide additional details (optional)
Preferred Start Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Preferred End Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Total Duration of Pause (in hours)
*
Supervisor/Manager Name
*
Supervisor/Manager Email Address
example@example.com
Signature (please sign to acknowledge your request)
*
Submit Request
Submit Request
Should be Empty: