RUNGE INDEPENDENT SCHOOL DISTRICT

ABSENT FROM DUTY REPORT

[insert employee #] [insert teacher name]

EMPLOYEE: ___________________________________ EMPLOYEE #: ________________

[insert date(s) of absence]

DATE(S) OF ABSENCE: ____________________

[X]

NUMBER OF DAYS ABSENT: ______

___________________________________

Signature of Employee

[move this box containing the symbol  to the corresponding leave type; delete all text when done] PLEASE INDICATE THE TYPE OF LEAVE YOU ARE REQUESTING:

Local Personal:	______	Non Duty Time:	______

State Personal:	______	Jury Duty:	______

State Sick Leave:	______	Workers Comp ______

[ insert description of school business ]

Comp Time In Hours	______	School Business: _______________________

Earned or Taken (Circle One)	(Write: Workshop # - Type of School Business)

(If Earned, please attach supervisor’s approval)

[insert substitute name(s) as appropriate [insert date]

SUBSTITUTES:	_________________________________	DATE: _________________

[insert substitute name(s) as appropriate [insert date]

_________________________________	DATE: _________________

[insert substitute name(s) as appropriate [insert date]

_________________________________	DATE:	_________________

[insert date] [insert substitute name(s) as appropriate

_________________________________	DATE:	_________________

[insert date] [insert substitute name(s) as appropriate

_________________________________	DATE:	_________________

___________________________________

Supervisor Signature

NOTE: Each employee must submit an Absent From Duty Report IMMEDIATELY after returning to duty. A written statement from the attending physician or practitioner must be submitted for an absence of more than five (5) consecutive days. The statement should appear on this form or be attached securely hereto.

(revised 10/15/2010)