Paid Absence Hours Redemption Request

First name

Last name

Number of Hours to be Redeemed:* [Note: Multiples of 4 hours]

Dates Absent:* Please list dates individually and not as a range.

Reason Absent:*
Illness: Within the previous twenty-four (24) hours, employee has/had a fever greater than 100.4 degrees, vomiting or diarrhea. Required Medical facility release if more than one day.Injury: All work-related injuries must be reported immediately while on duty.Health Related Appointments: Whether illness or preventative care.Health Attendant: Care of employee's child or domestic partner.Child Care: When an emergency at employee's school or childcare forces closure.Other

If “Other” is picked, please provide explaination:

Medical Facility Release, if needed, given to: