Workplace Injury Recovery Time-Off Form
Please fill out this form to request time off for recovery from a workplace injury.
Full Name
First Name
Last Name
Department
Date of Injury
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expected Recovery Period (days)
Start Date of Time-Off
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date of Time-Off
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Description of Injury
Doctor's Note Upload (if available)
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