Medical Leave Extension Form
Please fill out this form to request an extension for your medical leave.
Full Name
First Name
Last Name
Employee ID
Department
Original Leave Start Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Original Leave End Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Requested Extension Start Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Requested Extension End Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Extension
Doctor's Note Upload (if applicable)
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