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: * / MM / 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...)