Paid Sick Leave Request Form
Employee Name
First Name
Middle Name
Last Name
Last 4 of SSN
Who did you notify regarding your call out.
Details regarding requested dates. Include the shift you called out for, any additional dates you are regularly scheduled for that you would like to be included in your paid sick leave request, and the reason you called out (if information is available).
Are you able to provide medical paperwork?
Yes
No
I would prefer not to.
By signing below, I certify that the information included on this form is accurate.
Submit
Should be Empty: