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
Date
Expected Recovery Period (days)
Start Date of Time-Off
-
Month
-
Day
Year
Date
End Date of Time-Off
-
Month
-
Day
Year
Date
Description of Injury
Doctor's Note Upload (if available)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: