PHN Absence Request Form

Use this form to document leave time you are taking.

Leave time may be taken in 15 minute (0.25 hours) increments.

Leave time must be taken [guided by language in the Unit A and Unit B agreements] when:
>You are unable to fulfill your F2F responsibilities (teaching, meetings, office hours, etc.).
>You are unable to fulfill your ONLINE course responsibilities.

Today's date Today's date / MM / DD YYYY
Name Name First Last
Email
Type of Leave

Type of Leave Personal/Sick Leave Required Court Service (typically jury duty) 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) and number of hours absent
Additional information and special instructions (Class cancelled sign posted, D2L instructions, etc.)