Class Absence Notification Request

Notification Reason

Given or Chosen Full Name:

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Preferred, Given, Chosen Full Name

UT email address:

Email address must be of a valid format.

Notification Type(Required):

This field is required.

Reason for your request(Required):

This field is required.

Your Information

Your Name

EID Number

DOB (YYYY-MM-DD)

Phone number

Additional Information

First Date of Absence(Required)

This field is required.

Date of Expected Return(Required)

This field is required.

Do you want all of your professors notified (as listed in your current course enrollment)?(Required) This field is required.

Please list the specific professor(s) you would like notified and the unique number for each class (e.g. Smith (23456)).: (Please note: The Student Dean of your College will also be notified) This field is required.

Brief description of the reason for absence: (For medical and mental health emergencies, specific HIPAA protected information (medical diagnoses, etc) do not need to be disclosed)(Required) This field is required.

Please indicate any additional support that may be helpful for you at this time (can select multiple):

Emergency Funds General Consultation with a Case Manager Legal Services Off-Campus Housing UT Outpost (food and professional clothing) N/A

You must make at least one selection.

I understand that referrals from this form will be received during normal business hours (M-F, 8AM - 5 PM) and are not monitored after hours, on weekends, or during official University holidays. Please contact UTPD at 911 if there is an immediate risk of harm to self or others prior to submitting this form(Required)

Yes, I understand.

You must make at least one selection.

I understand that with appropriate documentation, my request will be processed within 2 business days and that if documentation is missing, it will increase the amount of time needed for processing.(Required)

Yes, I understand.

You must make at least one selection.

Supporting Documentation

Please provide any supporting documentation you have that can help explain the reason for your absence(s). With appropriate documentation, your request will be processed within 48 business hours. If documentation is missing, it will increase the amount of processing time. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Notification Reason

Your Information

Additional Information

Supporting Documentation

Submission