Time off request and record sheet
A printable from Political Activity at Work. Fill it in by hand. Nothing you write is collected by this website.
Time off request and record sheet
Asking for time off (send in writing, keep a copy) "Hello ______. I would like to take ______ (date) off. I would like to use my ______ (vacation / paid time off / an unpaid day). Please let me know by ______. Thank you."
- Sent on (date): ______ by (text / email / letter)
- Answer received on (date): ______ Yes / No
- If no, the reason given: ______________________
If I was punished, write down
- Date and place of the protest or activity: ______
- Was I on the clock? Yes / No
- What my boss said, and who heard it: ______________________
- Date of the punishment: ______ (fired / hours cut / demoted / written up / threatened)
- How others were treated for similar things: ______________________
- Copies of texts, emails, schedules and pay stubs saved: Yes / No
Deadlines
- Labor Commissioner retaliation complaint: within 1 year of the punishment
- National Labor Relations Board charge (if I acted with coworkers about our job): within 6 months
Help: Labor Commissioner 833-526-4636. Legal Aid at Work, East Palo Alto line (415) 404-9093.
Do not write your immigration status on this sheet.
From Political Activity at Work. Facts checked October 21, 2026. Free information, not legal or medical advice.