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Dept. of Human Services Absence Notification Form - Civil Service

Name: Name: First Last
Email:
Date of Absence: Date of Absence: / MM / DD YYYY
Type of Used Leave:

Type of Used Leave: Sick Leave Vacation Court Required Leave Bereavement Leave (3 days per occurance) Family Medical Leave (FMLA)
Total Hours:
Leave Reported in Quarter-Hour Increments
Date of Absence: Date of Absence: / MM / DD YYYY
Type of Used Leave:

Type of Used Leave: Sick Leave Vacation Court Required Leave Bereavement Leave (3 days per occurance) Family Medical Leave (FMLA)
Total Hours:
Leave Reported in Quarter-Hour Increments
Date of Absence: Date of Absence: / MM / DD YYYY
Type of Used Leave:

Type of Used Leave: Sick Leave Vacation Court Required Leave Bereavement Leave (3 days per occurance) Family Medical Leave (FMLA)
Total Hours:
Leave Reported in Quarter-Hour Increments
Date of Absence: Date of Absence: / MM / DD YYYY
Type of Used Leave:

Type of Used Leave: Sick Leave Vacation Court Required Leave Bereavement Leave (3 days per occurance) Family Medical Leave (FMLA)
Total Hours:
Leave Reported in Quarter-Hour Increments
Date of Absence: Date of Absence: / MM / DD YYYY
Type of Used Leave:

Type of Used Leave: Sick Leave Vacation Court Required Leave Bereavement Leave (3 days per occurance) Family Medical Leave (FMLA)
Total Hours:
Leave Reported in Quarter-Hour Increments
List the days/times you were absent if you were not absent a whole day (e.g., 3/1/24 - Gone from 1-4:30)