Cancer Screening Leave
Your name
Your name
*
First
Last
Your phone number
Your phone number
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Your district email address:
*
Confirm email address:
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Your position
Date of screening:
Date of screening:
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MM
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DD
YYYY
Please upload an image or pdf of verification from your health care provider that you were seen on the date and time listed above.
Verification must include your name, date and time of procedure, type of procedure performed, and provider's name and signature.
*
Attach Files
Please sign below and submit to complete your cancer screening leave request:
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Full Name
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