Migraine Sick Leave Request Form
Use this Migraine Sick Leave Request Form to notify your employer of a migraine-related absence. Please complete all required fields.
Full Name
*
First Name
Last Name
Employee Email Address
*
example@example.com
Department
*
Please Select
Human Resources
Finance
Operations
IT
Sales
Marketing
Other
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Absence
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expected Return Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is this absence due to a migraine?
*
Yes
No
Manager or Supervisor Name
*
Additional Comments (optional)
Employee Signature
*
Submit Request
Submit Request
Should be Empty: