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Excused Absence Notification Form
The completed form and any appropriate supporting documentation must be submitted to the
instructor fourteen (14) calendar days in advance of the day of the scheduled absence.
There are no exceptions to this deadline.
Student Name: ______________________________________________________________________
Student ID#: ______________________ Semester: ______________________
Course: ____________________________________________________________________________
Date(s) of absence: _____________________________________________________
Reason for the excused absence:
☐ Religious Observance
☐ Other: ____________________________________________________________________
Student Signature _______________________________ Date Submitted ___________________
Instructor Signature _______________________________ Date Submitted ___________________
To be completed by instructor
Description of work to be completed: ____________________________________________________
Deadline(s) for completion (please specify exact date(s)): ____________________________________
Original: Instructor 10/19/2017
Copy: Student
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