Absence Form

This form is used for Care Coordinators to report their absences to their LCs and to DOCOM.

Your Name:*
What are you missing?*
Please indicate the type of shift or event you will be missing.
Your Clinic Shift:*
Please indicate your original shift (the shift you are missing).
Your Clinic Time:*
Please indicate the time of your clinic shift (the shift you will be missing).
Your Care Coordination Shift:*
Please indicate the day of your original shift (the shift you are missing).
Your Care Coordination Time:*
Please indicate the time of your original shift (the shift you are missing).
Date You Will Be Missing*
MM slash DD slash YYYY

Please indicate the date that you will be missing.
Care Coordinator Covering for You:*
Please indicate the name of the Care Coordinator who will be covering your shift while you are absent. Of note, first semester CCs cannot cover your clinic shift.
Will you be swapping shifts with the Care Coordinator listed above?*
Day of the New Clinic Shift*
You indicated that you are swapping shifts with someone. What day is that new day?
New Care Coordination Shift:*
Which Care Coordination shift will you be going to instead? Please keep in mind that you can only go to this shift if there is space for you. Contact the LC at the shift you want ahead of time to confirm before picking a day to come in to do your shift.
Time of the New Shift*
You indicated that you are swapping shifts with someone. What time is that new shift?
Date of the New Shift*
MM slash DD slash YYYY

What day is the shift you are switching into?
Date of the New Shift*
MM slash DD slash YYYY

What day is the Care Coordination shift you will be going to instead? Please keep in mind that you can only go to this shift if there is space for you. Contact the LC at the shift you want ahead of time to confirm before picking a day to come in to do your shift.
Description of Absence*
Please give a detailed description of why you will be absent.
Evidence of Absence*
Drop files here or

Accepted file types: jpg, gif, png, pdf, docx, Max. file size: 125 MB.
Please provide any evidence that you might have of your absence. Example: Screenshot of an exam date, plane ticket, etc.
Please Note: You are responsible for making up your absence by the end of the semester. If you fail to make up your Care Coordination shift , you will receive a Disciplinary Action.*
I understand the note above.
Please Note: You are responsible for finding another CC who will cover for your clinic shift on the day of your absence. If you fail to do so, you will receive a Disciplinary Action.*
I understand the note above.
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