Sick Leave Request
Please complete this form any time you are sick AND scheduled to work (regular scheduled days).  Sick leave cannot be taken on Holidays.  It is best to submit this form on the day of your absence or the day you return to work or even when you get your next doctor appointment.  HR will contact you to follow up once your request has been reviewed.
Thank you!
Sign in to Google to save your progress. Learn more
Today's Date *
MM
/
DD
/
YYYY
Your Full Name *
Your Email Address (Optional)
Your Phone Number (Optional)
Last four digits of your SS# *
Department *
First date of Sick Leave *
MM
/
DD
/
YYYY
Last Date of Sick Leave *
MM
/
DD
/
YYYY
Total Number of Sick Leave hours/days to be paid *
Signature Required after Review
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms