Please enable JavaScript in your browser to complete this form.Email *EmailConfirm EmailName *FirstLastCurrent date *If leaving early, time left? *Department *Supervisor *For requested amount of time off *Requested amount of time off (Please write in next field)End of shift – Your scheduled hoursRequested amount of time off (Hours___ Minutes____) Leave begin date *Expected return date *Last 4 of Social security number *I am requesting sick leave for the following (Choose One) *The employee has a mental or physical illness, injury, or health condition; needs a medical diagnosis, care, or treatment related to such illness, injury, or condition; or needs to obtain preventive medical care;The employee has a mental or physical illness, injury, or health condition; needs a medical diagnosis, care, or treatment related to such illness, injury, or condition; or needs to obtain preventive medical care;The employee needs to care for a family member who has a mental or physical illness, injury, or health condition; needs a medical diagnosis, care, or treatment related to such illness, injury, or condition; or needs to obtain preventive medical care;The employee or family member has been the victim of domestic abuse, sexual assault, or harassment and needs to be absent from work for purposes related to such crime; orA public official has ordered the closure of the school or place of care of the employee’s child or of the employee’s place of business due to a public health emergency, necessitating the employee’s absence from work.Bereavement, or financial/legal needs after a death of a family memberDue to inclement weather, power/heat/water loss or other unexpected event, the employee must evacuate their residence or care for a family member whose school or place of care was closed.I hereby certify under penalty of perjury that to the best of my knowledge the information that I have provided for this request is accurate. I understand that it is my responsibility to inform my supervisor or Human Resources immediately of any change in circumstance related to the reason for my leave. Employee Signature *Clear SignatureSubmit
