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Absence reporting form

Fields identified by an asterisk (*) are mandatory

Employee
First and last name *:
Home phone number (000-000-0000) *:
Authorization to leave a message *:  Yes    No 
Date of birth:
Occupation:
   
Date of leave of absence:
Date planned for return to work:
   
Employer
Company name *:
Contact Name *:
Phone number (000-000-0000):
Fax number (000-000-0000):
Email *:
The employee signed the attached authorization that you print and keep for your record *:  Yes    No 

PDF Authorization form (pdf)
   
Additional Information
Kindly indicate the elements that caused the leave of absence and the possible obstacles that may delay the return to work.