Personal Day Accommodation Request Form

Personal Day Accommodation Request Form - Vaccine

To request a Personal Day accommodation please complete the following request form and submit it as soon as possible. A copy of records indicating that vaccine was received, or other supporting documents to substantiate the request must be included with this application before consideration shall be granted.
Employee Name*

First NameLast Name
District*
Campus*
Title*
Email*
example@example.com
First vaccine date*

MonthDayYear
Date
Second vaccine date*

MonthDayYear
Date
The anticipated data for Personal Day to be used*
Upload any relevant documents*

Cancelof
Signature*

Clear
By signing this document, you hereby certify under penalty of law that your request for Personal Day accommodation and records indicating that the vaccine was received are accurate. I understand that the school can immediately terminate my employment for falsifying my condition.
Should be Empty:

Personal Day Accommodation Request Form - Vaccine