The University of Texas Houston
Health Science Center

Sick Leave Report Form

p Health Science Center – General p School of Public Health
p Medical School p School of Nursing
p Dental Branch p Speech and Hearing Institute
p Graduate School of Biomedical Sciences p Division of Continuing Education
p Allied Health Sciences School

 

Name ________________________________________________________________________

Date _____________________
 
Department ___________________________________________________________________
Application is here requested for approval of the following sick leave:
From ___________________

19_________

Through ___________________

19________________
Total Working Hours Absent _______________
General Nature of Illness _______________________________________________________________________________________
__________________________________________________________________________________________________________
The above named person, who has been under my care for the condition stated on this form, is capable of resuming
his/her normal work schedule effective _____________________________________________________

19 ________________
Signature of Attending Physician ________________________________________________________________________________
Employee’s Signature _________________________________________________________________________________________
Program Director/Department Head _______________________________________________________________________________
Approved Disapproved Signature of Dean ___________________________________________________________
Routing: Department holds third copy; forwards original and second copy to Dean’s Office for approval. Approval original is sent to Personnel Office and second copy back to department.