All employees wishing to use accrued sick pay hours must complete this form.
First Name
*
Last Name
*
Email
*
Phone
*
Sick Pay Request Date
*
Number of Sick Hours Requested
*
(Minimum 2 hours, maximum not to exceed actual length of scheduled shift or accrued hours.)
Reason for Absence
*
Scheduled Medical Appointment
Unforeseen Illness
To Provide Care for a Family Member
Absence Due to Domestic Violence
No elements found. Consider changing the search query.
List is empty.
(Select one)
Details
*
(Provide details for your selection)
Submit