Midwood Medical Absence

IMPORTANT

DAYS EXCUSED WITH PAY FOR PERSONAL ILLNESS DEDUCATIBLE FROM C.A.R. OR SICK BANK

TWO TYPES OF FORM SUBMISSIONS: CONSECUTIVE and NON-CONSECUTIVE

CONSECUTIVE - Absences without interruption from a work day(weekends don't count)
NON-CONSECUTIVE - Absence(s) not following one another.

Empolyee Information Collection

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

DOE Email Address *

School Name *

School Year *

School Location *

Title *

File Number *

Absence Application Type *

Consecutive

Non-Consecutive

Is this for a full day absent or is this a fractional absence? * 🛈

Full Day

Fractional

Please bring your documentation to payroll in room 131 *

Fraction absences are not collected through this form.

Consecutive Absences Details

Start Date * +

End Date * +

Brief Description for Consecutive Medical Absences. *

Documentation Upload - Consecutive Absences *

Non-Consecutive Absence(s) Details

Non Consecutive Absence - Day 1 * +

Documentation Upload - Non Consecutive Absence - Day 1 *

Brief Description Non-Consecutive Absence - Day 1 *

Is There a 2nd Date to Report? *

Yes

No

Non Consecutive Absence - Day 2 * +

Documentation Upload - Non Consecutive Absence - Day 2 *

Brief Description Non-Consecutive Absence - Day 2 *

Is There a 3rd Date to Report? *

Yes

No

Non Consecutive Absence - Day 3 * +

Documentation Upload - Non Consecutive Absence - Day 3 *

Brief Description Non-Consecutive Absence - Day 3 *

Is There a 4th Date to Report? *

Yes

No

Non Consecutive Absence - Day 4 * +

Documentation Upload - Non Consecutive Absence - Day 4 *

Brief Description Non-Consecutive Absence - Day 4 *

Is There a 5th Date to Report? *

Yes

No

Non Consecutive Absence - Day 5 * +

Documentation Upload - Non Consecutive Absence - Day 5 *

Brief Description Non-Consecutive Absence - Day 5 *

Is There a 6th Date to Report? *

Yes

No

Non Consecutive Absence - Day 6 * +

Documentation Upload - Non Consecutive Absence - Day 6 *

Brief Description Non-Consecutive Absence - Day 6 *

Is There a 7th Date to Report? *

Yes

No

Non Consecutive Absence - Day 7 * +

Documentation Upload - Non Consecutive Absence - Day 7 *

Brief Description Non-Consecutive Absence - Day 7 *

Is There a 8th Date to Report? *

Yes

No

Non Consecutive Absence - Day 8 * +

Documentation Upload - Non Consecutive Absence - Day 8 *

Brief Description Non-Consecutive Absence - Day 8 *

Is There a 9th Date to Report? *

Yes

No

Non Consecutive Absence - Day 9 * +

Documentation Upload - Non Consecutive Absence - Day 9 *

Brief Description Non-Consecutive Absence - Day 9 *

Is There a 10th Date to Report? *

Yes

No

Non Consecutive Absence - Day 10 * +

Documentation Upload - Non Consecutive Absence - Day 10 *

Brief Description Non-Consecutive Absence - Day 10 *