Employee COVID-19 Work Excuse Form
Submit work-related absence dates and request details. Please do not include medical details.
Employee name
*
First Name
Last Name
Work email
*
example@example.com
Department or team
*
Supervisor name
*
First Name
Last Name
First date absent
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Last date absent
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expected return-to-work date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Work-excuse request type
*
Absence documentation
Schedule adjustment
Other
Optional brief work-related note — do not include medical details
I confirm the information provided is accurate.
*
I confirm
Submit request
Should be Empty: