Workers' Compensation Time Off

Employee FIT ID Number*

Please enter your FIT ID number.

Employee First Name*

Please enter your first name.

Employee Last Name*

Please enter your last name.

Employee Work Schedule*

Please enter your work schedule (days/times).

Employee FIT Email Address*

Please enter your FIT e-mail address.

First Day of Absence*

Please enter the first day of absence.

Last Day of Absence*

Please enter the last day of absence.

Supervisor Name*

Please enter your supervisor's name.

Supervisor Email*

Please enter your supervisor's FIT e-mail address.

Send me a copy of my responses