Absence From Duty

Absence From Duty

Custodial, Groundskeeper, Maintenance
Employee Name

First NameLast Name
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Applicaton is hereby made for approval of absence from duty for the period.
Beginning Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Ending Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Total Day(s) Absent
Reason for Absence

Other
Note: Scheduled 10 hr. work days equivalent to 1.25 days.
Facts concerning the above absence from duty
Employees must report their absence as soon as they return to work. If the absence lasted five or more consecutive workdays, a written statement from the attending physician must also be submit.
Employee Signature
Employee Email
example@example.com
Should be Empty: