United Employment Solutions: Sick Form

Please only fill out this form if you are an active and working employee with United Employment Solutions. This is not valid for applicants. You must be working at a site. Thank you.

Name *

First

Middle

Last

Last 4 SSN *

Please provide the last 4 SSN that is associated with your account.

Phone Number *

Date / Time *

Date

Time

Number of Days Requested *

Please Choose the Type of Leave *Sick TimePersonal LeaveJury DutyMilitary LeaveTime Off RequestFamily and Medical LeaveBereavement LeaveTime Off to Vote

Please choose one. Please not that this is a request and is not guaranteed to be paid or excused. We will review each request and determine by each case.

Time Off Request Comments *

Please describe your situation and why you need time off.

Submit