RTO Request Form

See policies 401 and 501. Staff employees must make RTO requests as far in advance as practicable. It is your responsibility to change your status on “Teams” as well as your auto response message in Outlook (email), voicemail message and any other telephone answering/forwarding services. DPI reserves the right to deny any RTO request based on business need.

Your Name*

Last NameFirst Name

Your Email*

example@thedpigroup.com

Supervisor/Approver's Email*

example@thedpigroup.com

Select RTO Reason: *

*Please consult the HR Dept regarding your leave of absence options.

Time Off Dates/Duration*

Any Additional Comment/Explanation

I understand that the parameters of the RTO program (including reasons for denial) as well as other leave options are described in the DPI Policies.
I understand that if the RTO request is due to a medical issue (for myself or to care for a family member) I will consult with my manager/HR to see if it is a Family Medical Leave (or state equivalent) situation.
I understand that I may be required to provide medical certification or other documentation to justify the RTO request, and that failure to provide adequate certification may result in a denial of my RTO request and/or disciplinary action.
I certify that all statements contained in this request are true and complete.
Any oral or written statements that are false and/or misleading may be grounds for disciplinary action.

Signature