EMPLOYEE (AB 1522) SICK LEAVE ABSENCE AFFIDAVIT
Pay Period from __________ to ___________
Department _____________________________; College: _________________________________
I, ________________________________________________________, certify that I was absent on
____________________________________________________ [list the date(s) of
Absence], for a total of _______ hours.
__________________________________ ____________________________________
Employee Signature Supervisor Signature
Date: __________________ Date: __________________
Employee ID #: __________________
Student ID #: __________________
This form is to be completed upon return to work and provided to the supervisor who will turn it in with the employee’s time sheet.