Original: Instructor 10/19/2017
Copy: Student
Pregnancy/Childbirth Excused Absence Notification Form
The completed form and any appropriate supporting documentation must be submitted to the
instructor as soon as possible once dates of absence are known and supporting documentation is
available.
Student Name: ______________________________________________________________________
Student ID#: ______________________ Semester: ______________________
Course: ____________________________________________________________________________
Date(s) of absence: _____________________________________________________
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)):____________________________________
__________________________________________________________________________________
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
