Call Out Form - United Way Of Connecticut

Callout Form for the UWC

Name(Required)

First Last

Your Department(Required)

I will be(Required)

In late today

Out all day today

In late tomorrow

Out tomorrow

Leaving Early Today

Leaving Early Tomorrow

Is this due to personal or family illness?(Required)

Or for obtaining care from a health care provider for yourself or a family member?

Yes

Time I will be in(Required)

Time I will be leaving at(Required)

If this is due to:
• The birth of a child or to care for the child within the first year after birth
• The placement of a child by adoption or foster care and to care for the child
• The need to care for a family member or someone close to you with a serious health condition
• Your own serious health condition
• To serve as an organ or bone marrow donor
• To care for a spouse, son, daughter, parent, or next of kin with a serious injury or illness incurred on active duty in the military
• To address an urgent need arising from active military duty or call to active duty of a spouse, son, daughter or parent
• Pregnancy or pregnancy-related sickness
• Injury on the job
• Jury duty

You may be entitled to leave or accommodation under federal or state law or company policy. Please contact Human Resources if you need more information.