Department of Public Health & Nutrition Absence Request Form
Department of Public Health & Nutrition Absence Request Form
Use this form to request leave from duties that requires the use of benefits.
Today's date:
Today's date:
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MM
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DD
YYYY
Name
Name
*
First
Last
Email
*
Type of Leave
*
Type of Leave
Personal/Sick Leave
Court Required Leave
Bereavement Leave
Is this leave being requested as part of an existing FMLA certification?
*
Is this leave being requested as part of an existing FMLA certification?
Yes
No
Date(s) of absence:
*
Total number of hours absent:
*
Additional information and special instructions: (Class cancelled sign, D2L instructions...)