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
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Month
-
Day
Year
Date
Original Leave End Date
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Month
-
Day
Year
Date
Requested Extension Start Date
-
Month
-
Day
Year
Date
Requested Extension End Date
-
Month
-
Day
Year
Date
Reason for Extension
Doctor's Note Upload (if applicable)
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