Dept. of Human Services Absence Notification Form - Civil Service

Name: Name: * First Last
Email: *
Date of Absence: Date of Absence: * / MM / DD YYYY
Type of Used Leave: *

Type of Used Leave: Sick Leave Vacation Court Required Leave Bereavement Leave Family Medical Leave (FMLA)
Total Hours:
Leave Reported in Quarter-Hour Increments *
Date of Absence: Date of Absence: / MM / DD YYYY
Type of Used Leave:

Type of Used Leave: Sick Leave Vacation Court Required Leave Bereavement Leave Family Medical Leave (FMLA)
Total Hours:
Leave Reported in Quarter-Hour Increments
Date of Absence: Date of Absence: / MM / DD YYYY
Type of Used Leave:

Type of Used Leave: Sick Leave Vacation Court Required Leave Bereavement Leave Family Medical Leave (FMLA)
Total Hours:
Leave Reported in Quarter-Hour Increments
Date of Absence: Date of Absence: / MM / DD YYYY
Type of Used Leave:

Type of Used Leave: Sick Leave Vacation Court Required Leave Bereavement Leave Family Medical Leave (FMLA)
Total Hours:
Leave Reported in Quarter-Hour Increments
Date of Absence: Date of Absence: / MM / DD YYYY
Type of Used Leave:

Type of Used Leave: Sick Leave Vacation Court Required Leave Bereavement Leave Family Medical Leave (FMLA)
Total Hours:
Leave Reported in Quarter-Hour Increments
List times for any date here that is not a full day (7.5 hours). List all dates/times that were not a full day here.