RC5 PA8C145
NEW YORK CITY DEPARTMENT OF EDUCATION
DIVISION OF HUMAN RESOURCES
65 Court Street, Brooklyn, N.Y. 11201
APPLICATION FOR EXCUSE OF ABSENCE FOR PERSONAL ILLNESS (SICK LEAVE)
This application is filed as
Purpose
Type a separate application for each non-consecutive absence within a month.
I. To be Completed by the Applicant
Full Name of Applicant
Start typing — pick your name from the list (or type it if you're not listed).
Home Address
Home ZIP
File #
School Number or Name
School Address
School District #
School ZIP
License
Years of Service
Appointment status
Dates of absence
Add each day you were absent
Pick a day and add it — repeat for each day. Non-consecutive days are fine.
No dates added yet.
Inclusive dates (auto-filled from the days above — edit if needed)
From
To
Time lost
Illness since September (this school year, including this absence)
Reason for absence (choose one)
II. Applicant declarations
Did you report for duty to any afternoon or evening activity of the DOE or Community Board on any date for which this excuse is requested?
Date
Signature of Applicant (type your full name)
The sections below are completed by the Principal, the physician, and the Medical Division. They are included so you can print the full official form — you don't need to fill them in to submit.
III. To be Completed by Principal (If Other Appropriate Supervisor, Show Title Below):
Date Signature of Principal (Title, if applicable)
IV. To be Completed by Physician or Other Authorized Practitioner (OP 407 is to be substituted for absence exceeding 20 consecutive school days or when report is confidential):
MEDICAL CERTIFICATION: As a duly licensed physician or other authorized practitioner, I certify that between the dates and the person named above was incapacitated for school duties and that I attended the individual on the following dates:

The technical designation of illness was:

commonly known as:
Physician's Address   Telephone
Typed or Printed Name
Date Signature of Physician M.D.
(If other than M.D., professional title is:)
V. To be Completed by Medical Division and Returned to School as Necessary:
Medical Recommendation Submitted as Noted Subject to All Administrative Requirements
Medically Approved Medically Disapproved
From To From To
Additional Remarks
Date Signature of Medical Director
Add your name, at least one absence date, and your signature — then the Submit button appears.