LASSEN COUNTY OFFICE OF EDUCATION ABSENCE FROM DUTIES FORM

LASSEN COUNTY OFFICE OF EDUCATION ABSENCE FROM DUTIES FORM

This form should be completed in advance to receive approval.
Name
Date Submitted

MonthDayYear
Date
Exact Date(s) of Absence

MonthDayYear
Date
Last Day Worked
Time of Day Absent
Day Returned
Total Number of Days/Hours Absent
Reason for Absence
Absence Types:
- Sick Leave
- Personal Necessity
- Leave Personal Leave
- Non-Duty Day
- Authorized Meeting/Office
- Business
- Jury Duty
- Bereavement Leave
- Workers' Compensation
- Vacation Leave
- Floating Holiday (Supervisor's Approval)
- Without Pay
With the exception of emergency situations, approval is required prior to absence.
Absence from Duty Type of Leave
Employee Signature

Clear
Supervisor Signature

Clear
Supervisor Date

MonthDayYear
Date
If absent for more than three (3) consecutive work days, physician's certification may be required:

This is to certify that_______________ was attended or advised by me in my capacity as a physician or medical advisor for the illness on the day or days noted above.
7/1/17 Common/FormsAbsence Form 7/1/2021 Revised
Should be Empty: